Sri Aurobindo Institute of Pharmacy, Indore-453555, Madhya Pradesh, India.
Background: Surgical site infections (SSIs) are infections occurring within one month of surgery or one year after implant surgery, at or near the surgical site. SSIs remain a significant global health concern, particularly in developing countries, contributing to increased morbidity and mortality. Data regarding the prevalence, bacterial causes, and associated risk factors of SSIs are limited at the study hospital. Aims: This study aimed to investigate the correlation between sterilization practices, antibiotic resistance, malnutrition, and surgical site infection in a tertiary care hospital. Materials and Methods: This hospital-based, prospective observational study was conducted at Sri Aurobindo Hospital, Indore, Madhya Pradesh. The study population included patients aged 25-70 years of both sexes, newly diagnosed with various types of SSIs requiring antimicrobial treatment. The prescribing patterns of antimicrobials and potential risk factors for SSIs were investigated. Results: Of the 63 study participants, the highest incidence of SSIs followed amputations (36.50%). The most affected age groups were 51-60 and 61-70 years, each comprising 20.14% of the cases. Diabetes mellitus was the most prevalent risk factor, present in 39.70% of patients with SSIs (n=25). The most common primary diagnosis leading to surgery and subsequent SSI was gangrene requiring amputation (36.50%, n=23). Escherichia coli was the predominant isolated organism (34.90%, n=12). Conclusion: The high prevalence of multidrug-resistant organisms serves as a warning sign for the increasing spread of antibiotic resistance. Accurate identification of SSIs relies on the interpretation of clinical and laboratory findings.
Surgical site infections (SSIs), occurring within 30 days of surgery, significantly contribute to postoperative morbidity and mortality. Prevention strategies include meticulous surgical technique, prophylactic antibiotics, and measures to minimize bacterial, viral, and fungal contamination from staff or the environment. This focuses on mechanical prevention of contamination. SSIs are a major category of healthcare-associated infections. Accurate diagnosis relies on a multifaceted classification system, enabling appropriate prevention and management. The CDC categorizes surgical wounds into four classes based on infection risk. "Clean" wounds, uninfected and non-inflammatory, require careful handling, especially during drainage. "Clean-contaminated" wounds involve the respiratory, gastrointestinal, or genitourinary tracts under controlled sterile conditions, with a low infection risk. "Contaminated" wounds appear sterile but involve incisions with acute, aseptic inflammation. "Dirty or infected" wounds, often from trauma, have pre-existing infection or foreign material contamination. CDC data indicates incision-related infections are prevalent and challenging to treat due to widespread antibiotic use, which disrupts beneficial bacteria crucial for healing. Preventing SSIs requires a comprehensive approach addressing all potential contamination sources and judicious antibiotic use. Effective infection control protocols are essential to minimize the impact of SSIs on patient outcomes. This includes proper sterilization, adherence to aseptic techniques, and surveillance to identify and address risk factors. Multidisciplinary collaboration is crucial for successful SSI prevention and management. Antimicrobials are crucial for preventing and treating surgical site infections (SSIs), which can significantly impact patient outcomes. SSIs, a type of healthcare-associated infection, can occur after any surgical procedure and are characterized by infection at or near the surgical incision within 30 days. They represent a substantial portion of all healthcare-associated infections, affecting a notable percentage of surgical patients. SSIs range in severity from minor wound discharge to severe complications like sternal infections. A majority of SSIs originate from contamination during surgery, often from the patient's own flora, while some arise from external sources. Prevention strategies are implemented across pre-, intra-, and postoperative phases. Antimicrobial prophylaxis, typically a single dose before incision, is a common preventive measure. The choice of antibiotic depends on the surgical procedure, patient history, and local resistance patterns. For diagnosed SSIs, antimicrobial therapy is guided by culture and sensitivity testing to identify the causative pathogen and its antibiotic susceptibilities. This targeted approach ensures effective treatment while minimizing the risk of resistance development. Judicious antimicrobial use is essential, involving appropriate dosage, duration, and consideration of potential adverse effects. SSIs can negatively impact patients' quality of life. The increasing trend of rapid discharge after surgery means more infections are now managed in primary care settings. Antimicrobials play a dual role: prophylaxis to prevent infection and therapy to treat established infections. Effective treatment reduces complications, shortens hospital stays, and lowers healthcare costs. However, responsible antimicrobial stewardship is paramount to combat the growing threat of antibiotic resistance. This includes adherence to established guidelines, careful selection of antibiotics, and ongoing surveillance of resistance patterns. By optimizing antimicrobial use, we can improve patient outcomes and preserve the effectiveness of these vital drugs. The development of new strategies and ongoing research are crucial to address the evolving challenges of SSI prevention and treatment in the face of increasing antimicrobial resistance.
MATERIALS AND METHODS
A Prospective and Observational Study was done at Sri Aurobindo Hospital-Bhawrasala, Indore-Ujjain Highway, Near MR10 Road, Indore, MP, 453555. The duration of the study was 6 months. The study was carried out by constructing the following inclusion and exclusion criteria after taking consent from the patients/attenders of the patients.
Inclusion criteria:
RESULTS
A total of 156 cases were approached and invited to take part in the study. The procedure was explained, and participants were invited to take part. Out of 63 applicants, 63 met the inclusion and exclusion criteria. This study of 63 surgical patients revealed a predominantly young adult population, with the largest group (25.4%) aged 21-30. Subsequent age groups showed a decreasing trend, with the smallest representation (7.94%) in the 41-50 year range. Males constituted a majority (65%) of the patient cohort. Comorbidity analysis revealed diabetes mellitus as the most prevalent condition (39.7%), followed by hypertension (28.6%), hypothyroidism (14.3%), and epilepsy (12.7%). A small percentage (4.8%) of patients presented with no recorded comorbidities. Regarding social history, smoking was reported in 55.6% of patients, alcohol use in 38.1%, and substance use in 6.3%. These findings provide valuable demographic and clinical data for understanding risk factors associated with surgical outcomes in this population.
Fig 1: Gender distribution of patients
Fig 2: Age distribution of patients
Fig 3: Type of Surgery
Of the 63 patients studied, 55.56% (n=35) had positive cultures, while 44.44% (n=28) were culture-negative. Among positive cultures, Escherichia coli was most prevalent (34.29%, n=12), followed by MRSA (28.57%, n=10), Klebsiella pneumoniae (22.86%, n=8), Acinetobacter baumannii (8.57%, n=3), and Enterococcus faecalis (5.71%, n=2). ESBL resistance was observed in 80% of MRSA, 50% of A. baumannii, 50% of K. pneumoniae, and 8.33% of E. coli isolates. Carbapenemase resistance was detected in 50% of MRSA and 100% of A. baumannii isolates. All patients survived; 33.33% (n=21) recovered and 66.67% (n=42) improved. Antimicrobial administration included amikacin (52.4%, n=33), metronidazole (19%, n=12), cefixime (12.7%, n=8), rifampicin (9.5%, n=6), and ceftriaxone (6.3%, n=4). Pre-operatively, 4.8% (n=3) of patients had no SSIs, while 95.2% (n=60) had at least one. Post-operatively, all patients developed at least one SSI. Wound type distribution was: Type I (22.2%, n=14), Type II (25.4%, n=16), Type III (23.8%, n=15), and Type IV (28.6%, n=18). Gram-negative sensitivity testing showed varying susceptibility patterns across isolates to the tested antibiotics. Similarly, Gram-positive isolates (MRSA and E. faecalis) demonstrated varying sensitivities to the tested antimicrobials. These findings provide crucial information on the prevalence of SSIs, causative organisms, resistance mechanisms, and treatment outcomes in this surgical population.
Table 1. Distribution Of Isolates
|
Distribution of isolates |
Total no. of patients(N=35) |
Percentage of patients (N=35) |
|
E. coli |
12 |
34.29% |
|
MRSA |
10 |
28.57% |
|
Klebsiella pneumoniae |
8 |
22.86% |
|
Acenetobacter baumanni |
3 |
8.57% |
|
Enterococcus faecalis |
2 |
5.71% |
|
Total |
35 |
100% |
Table 2. Analysis of culture positivity distribution of patient
|
Analysis of culture positivity distribution of patient |
Total no. of patients(N=35) |
Percentage of patients (N=35) |
|
Culture Positive |
35 |
55.56 |
|
Culture Negative |
28 |
44.44 |
|
Total |
63 |
100 |
Fig 4: Type Of Antimicrobial Drugs
Table 3. Type of Wound
|
Type of Wound |
Total no. of patients (N=63) |
Percentage of patients (N=63) |
|
I |
14 |
22.2 |
|
II |
16 |
25.4 |
|
III |
15 |
23.8 |
|
IV |
18 |
28.6 |
|
Total |
63 |
100 |
Statistical analysis revealed significant associations between several variables in this study of surgical site infections. Age, gender, and type of surgery demonstrated a statistically significant interrelationship (p=0.029, likelihood ratio p=0.022). A significant correlation was also found between the type of surgery performed and the antimicrobials administered (p=0.044, likelihood ratio p=0.032). Furthermore, the type of surgery was significantly associated with the type of wound (p=0.044, likelihood ratio p=0.032), pre-operative stay duration (p=0.039, likelihood ratio p=0.040), and post-operative stay duration (p=0.038, likelihood ratio p=0.035). Culture positivity was significantly associated with the distribution of bacterial isolates (p=0.025, likelihood ratio p=0.033). Critically, a highly significant association was observed between the type of surgery, antimicrobial usage, and patient outcome (p<0.001, likelihood ratio p=0.045). These findings suggest that age, gender, surgical procedure, antimicrobial selection, wound type, and length of hospital stay are all interconnected factors influencing the risk and outcomes of surgical site infections. The strong association between surgical type, antimicrobial use, and patient outcome underscores the importance of appropriate surgical techniques, judicious antimicrobial stewardship, and comprehensive patient management in minimizing the burden of SSIs. The statistically significant relationships between these variables highlight potential areas for targeted interventions to improve patient outcomes and reduce the incidence of SSIs. Further research is warranted to explore the complex interplay of these factors and to develop evidence-based strategies for SSI prevention and treatment. These results provide valuable insights into the factors contributing to SSIs in this patient population.
|
Table 4. Sensitivity pattern of Gram negative |
|||
|
Antimicrobials |
K. pneumoniae (13) |
A. baumannii (7) |
E. Coli (15) |
|
Metronidazole |
3 |
1 |
1 |
|
Amikacin |
1 |
2 |
2 |
|
Cefixime |
4 |
1 |
5 |
|
Rifampicin |
2 |
2 |
3 |
|
Ceftriaxone |
2 |
1 |
4 |
|
Table 5. Sensitivity pattern of Gram Positive |
||
|
Antimicrobials |
MRSA (17) |
Enterococcus faecalis (11) |
|
Metronidazole |
6 |
3 |
|
Amikacin |
4 |
1 |
|
Cefixime |
3 |
4 |
|
Rifampicin |
2 |
2 |
|
Ceftriaxone |
2 |
1 |
Fig 5: Correlation between type of surgery and antimicrobials
Fig 6: Correlation Between Type of Surgery and Wound
Fig 7: Correlation between type of antimicrobials and outcome
DISCUSSION
This study, conducted at Sri Aurobindo Institute of Medical Sciences, Indore, analyzed 63 surgical patients, categorized by wound type (clean, clean-contaminated, contaminated, and dirty). The highest SSI incidence was observed in the 20-30 age group, likely due to a higher volume of surgeries in this demographic. Males exhibited a significantly higher infection rate (65%) than females (34.92%). The overall SSI rate of 22.67% aligns with other Indian studies, which report a wide range (6.09% to 38.7%), but is higher than rates in the US and Europe (0.5% to 15%), potentially due to variations in hospital infrastructure and infection control practices. SSI incidence increased with patient age, a finding consistent with other research. Emergency surgeries were associated with higher SSI rates, possibly due to the nature of wounds, patient comorbidities, and less time for pre-operative preparation. Clean surgeries had lower SSI rates compared to dirty procedures. Longer post-operative stays correlated with increased SSI risk, potentially reflecting illness severity, comorbidities, or nosocomial infection acquisition. This aligns with studies showing increased SSI risk with longer hospital stays, both pre- and post-operatively. Factors contributing to increased SSI risk in later elective surgeries include operating room contamination, scheduling of contaminated cases later in the day, declining aseptic practices, and surgical team fatigue. Studies have shown a significant association between SSI rates and both surgical order and duration. Comorbidities like diabetes and COPD significantly increase SSI risk. The most common isolated organisms were multidrug-resistant, including MRSA, highlighting the urgent need for evidence-based antibiotic policies and stringent infection control. The study emphasizes the multifactorial nature of SSI development, involving patient demographics, surgical factors, and hospital practices, and reinforces the importance of comprehensive infection control strategies.
CONCLUSION
Surgical site infections (SSIs) remain a significant post-surgical complication. Established risk factors include advanced age, prolonged hospitalization, extended surgical time, surgical sequence, prolonged drainage, emergency procedures, wound classification, and contamination. While antimicrobial prophylaxis is effective, its judicious and timely use is crucial to mitigate resistance development. The relatively low SSI incidence in this study may be attributed to newer facilities and robust infection control, though further reduction through stringent aseptic measures and rational antibiotic policies is a continuous goal. Effective SSI management necessitates a comprehensive approach encompassing prevention, timely prophylactic antimicrobials, and prompt, targeted treatment of established infections. Antimicrobial stewardship is essential to balance therapeutic benefit with minimizing resistance. Continuous research and adherence to evidence-based guidelines are vital for optimizing patient outcomes. A multi-pronged strategy integrating vigilant prevention, precise antimicrobial use, and innovative treatments is crucial to decrease the burden of SSIs, ultimately improving patient safety and healthcare quality. This includes ongoing surveillance, education of healthcare professionals, and implementation of best practices in surgical and post-operative care. Further research exploring novel preventive and therapeutic approaches is also warranted. The ultimate goal is to minimize the occurrence of SSIs and improve the overall well-being of surgical patients.
REFERENCES
Tishank Sinha*, Arshita Kumari, Avneel Kumar Kushwaha, Infection on Surgical Site Post-Operation and The Use of Antimicrobials to Treat the Infection, Int. J. of Pharm. Sci., 2025, Vol 3, Issue 7, 12-21. https://doi.org/10.5281/zenodo.15779548
10.5281/zenodo.15779548
