Surgical site infection—the next frontier in global surgery
Authors: Robert G Sawyer, Heather L Evans
Journal: The Lancet Infectious Diseases (2018)

In this issue of The Lancet Infectious Diseases, the GlobalSurg Collaborative1GlobalSurg CollaborativeSurgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study.Lancet Infect Dis. 2018; (published online Feb 13.)http://dx.doi.org/10.1016/S1473-3099(18)30101-4Google Scholar report the incidence of surgical site infection (SSI) from an international, multicentre, prospective cohort of consecutive patients undergoing elective or emergent gastrointestinal resection during the first 6 months of 2016. To document SSI in 343 centres across 66 countries in Africa, Asia, Europe, North America, Oceania, and South America is an impressive undertaking that substantially adds to our understanding of the global problem of post-operative infections and their associated morbidity and mortality. Participating centres were stratified by high-income, middle-income, and low-income groups according to each country's human development index (HDI), the UN's composite statistic of life expectancy, education, and income indices. The primary outcome was SSI incidence within 30 days after surgery, and the secondary outcomes were mortality and number of patients needing re-intervention within 30 days, perioperative antibiotic usage, and antimicrobial resistance of microorganisms. Limiting the eligible study cohort to patients undergoing clean–contaminated, contaminated, and dirty surgical procedures, the investigators report an overall 30-day SSI incidence of 12·3%, ranging from 9·4% in high-HDI countries to 23·2% in low-HDI countries. HDI was an independent risk factor for SSI irrespective of degree of intra-operative contamination. There is clearly an opportunity and an imperative to improve outcomes in low-income countries, particularly with the expected association between SSI and mortality, re-intervention, and increased length of hospital stay. WHO guidelines for SSI prevention outline a roadmap for such quality improvement—recommendations that go beyond the scope of the simpler WHO Surgical Safety Checklist.2Allegranzi B Bischoff P de Jonge S et al.New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective.Lancet Infect Dis. 2016; 16: e276-e287Summary Full Text Full Text PDF PubMed Scopus (393) Google Scholar, 3Allegranzi B Zayed B Bischoff P et al.New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective.Lancet Infect Dis. 2016; 16: e288-e303Summary Full Text Full Text PDF PubMed Scopus (437) Google Scholar, 4WHOWHO surgical safety checklist.http://www.who.int/patientsafety/safesurgery/checklist/en/Google Scholar It is interesting that surgical procedures that did not include a checklist were associated with a similar risk of SSI as procedures during which a checklist was available and used, whereas having access to a checklist but not using it was associated with an increased incidence of SSI. These data suggest that it is not the checklist itself that improves outcomes, but a cultural willingness to follow established, local protocols for infection prevention.5Haynes AB Weiser TG Berry WR et al.Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention.BMJ Qual Saf. 2011; 20: 102-107Crossref PubMed Scopus (340) Google Scholar The data, however, are not granular enough to assess adherence to accepted practice for antimicrobial prophylaxis. Although the investigators fall short of recommending practice change towards shortened antimicrobial treatments, the relative overuse of antibiotics in low-income and middle-income countries, particularly in the post-operative period, is associated with increased antimicrobial resistance. If this is truly the most important contributor to the SSI problem, an enhanced effort in antimicrobial stewardship will also need to be implemented. This study is notable for the lengths to which the investigators went to validate data collection and reporting, which included qualitative interviews of centre data abstractors to affirm adherence to study procedures. Their findings are consistent with those of previous studies in that prospective, intentional follow-up is associated with increased incidences of SSI; 45% of SSI were detected after discharge from hospital.6Woelber E Schrick E Gessner E Evans HL Proportion of surgical site infection occurring after hospital discharge: A systematic review.Surg Infect (Larchmt). 2016; 17: 510-519Crossref PubMed Scopus (56) Google Scholar However, in-person, 30-day follow-up was not feasible across the entire cohort, and the substantial reliance on post-discharge telephone reporting is especially problematic because patients are unreliable for discernment of SSI.7Whitby M McLaws M-L Collopy B et al.Post-discharge surveillance: can patients reliably diagnose surgical wound infections?.J Hosp Infect. 2002; 52: 155-160Summary Full Text PDF PubMed Scopus (82) Google Scholar The investigators concede that even this degree of prospective follow-up might not be feasible in usual care, particularly the care that is delivered in low-resource settings. Whether the variance in cultural norms and post-operative patient education between countries and HDI strata has an effect on the detection of SSI is also unclear. mHealth tools that support wound evaluation after discharge from hospital could make personalised, remote follow-up and targeted treatment possible by standardising patient and provider education with photographs or video examples of SSI, or by facilitating real-time monitoring with text-based communications.8Armstrong KA Coyte PC Brown M Beber B Semple JL Effect of home monitoring via mobile app on the number of in-person visits following ambulatory surgery: a randomized clinical trial.JAMA Surg. 2017; 152: 622-627Crossref PubMed Scopus (77) Google Scholar, 9Evans HL Lober WB A pilot use of patient-generated wound data to improve postdischarge surgical site infection monitoring.JAMA Surg. 2017; 152: 595-596Crossref PubMed Scopus (19) Google Scholar The GlobalSurg Collaborative clearly describe the magnitude of the problem of SSI in all care settings but particularly in resource-stressed environments. Although the idea that an SSI is just an SSI is prevalent, it is now well known that the cost of an SSI in terms of mortality, morbidity, health-care costs, and loss of productivity is enormous. Use of guidelines, such as those by WHO, has the promise of both human and economic gains that cut across the economic spectrum. In essence, an ounce of prevention is worth a pound, yuan, birr, or peso of cure. We declare no competing interests. Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort studyCountries 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. Full-Text PDF Open Access