Surgical site infection among gynecological group: risk factors and postoperative effect
Keywords:Gynecological surgery, Postoperative impact, Risk factors, Surgical site infection
Background: This study was carried out to evaluate the preoperative and intraoperative risk factors associated with surgical site infection amongst gynecology patients and its impact on postoperative recovery.
Methods: A prospective, observational study was conducted among 285 patients
Who underwent surgery over a period of two years. Diagnosis of SSI was made as per CDC criteria. Various risk factors and impact of SSI on postoperative recovery were analysed. Statistical analysis was carried out with SPSS version 16.0. Range and mean was calculated for continuous variables and overall incidence rate of SSI is also calculated. Pearson Chi-square test was used to test risk factor association with SSI. Odds ratios and 95% confidence intervals (CI) was calculated. Significance was assumed at a p value of less than 0.05.
Results: The incidence of SSI was found to be 52 out of 285 women (46%). Majority of SSI, i.e. 49 out of 52 (94%) were superficial in nature. Deep SSI was seen in 3 patients (6%). No organ/space infection was noted in any patient. Women who were over 50 years had higher risk of developing SSI than women between 36 to 50 years (OR 0.519 Vs 0.214). The risk of SSI was 4 times in case of clean contaminated wounds as compared to clean wounds (OR 3.877). The risk further increased to 7 times in case of dirty wounds (OR 6.753). Other risk factors which are significantly associated with SSI were BMI (p value <0.001), midline incisions (p <0.001) and Mattress suture (p <0.001). Presence of previous scar had intraoperative adhesions, weaker scar and poor healing which predispose to development of SSI. Comorbidities which influence SSI’s in the present study are diabetes mellitus (OR 5.49, 95% CI 2.506-12.066, P <0.001), anaemia (OR 4.63, Cl 2.458-8.756) and hypertension (OR 2.46, Cl 0.994-6.117). Wound swab was sterile in 33(63%) cases and 18(35%) cases showed growth of the organism. Most common organism noted was E. coli 9 (50%) followed by Klebsiella and Staph aureus.
Conclusions: SSIs are increasing in the current scenario due to increase in the number of surgeries, however they can be prevented by early identification and optimization of medical comorbidities and BMI. Meticulous preoperative workup and intraoperative surgical steps are important in reducing the risk of developing SSI. A decrease in infection rate can lead to substantial reduction in the burden of disease.
World Health Organization 2016: Global guidelines on the prevention of surgical site infection. Available at http://www.who.int/gpsc/global-guidelines-web.pdf
Black JD, de Haydu C, Fan L, Sheth SS. Surgical site infections in gynecology. Obstet Gynecol Surv. 2014; 69(8):501-10.
Olsen MA, Higham-Kessler J, Yokoe DS, Butler AM, Vostok J, Stevenson KB et al. Prevention epicenter program CfDC, prevention: developing a risk stratification model for surgical site infection after abdominal hysterectomy. Infect Control Hosp Epidemiol. 2009;30(11):1077-83.
Shahane V, Bhawal S, Lele MU. Surgical site infections: A one year prospective study in a tertiary care center. Int J Health Sci. 2012 Jan;6(1):79-84.
Bangal VB, Borawake SK, Shinde KK, Gavhane SP. Study of Surgical Site Infections following Gynaecological Surgery at tertiary care teaching hospital in Rural India. Int J Biomed Res. 2014 Feb;5(2):113-6.
Shrestha S, Shrestha R, Shrestha B, Dongol A. Incidence and Risk Factors of Surgical Site Infection Following Cesarean Section at Dhulikhel Hospital. Kathmandu Univ Med J. 2014;46(2):113-6.
Pathak A, Mahadik K, Swami MB, Roy PK, Sharma M, Mahadik VK et al. Incidence and risk factors for surgical site infections in obstetric and gynecological surgeries from a teaching hospital in rural India. Antimicrob Resist Infect Control. 2017;6:66.
Gregor M, Paterová P, Buchta V, Ketřánek J, Špaček J. Healthcare‐associated infections in gynecology and obstetrics at a university hospital in the Czech Republic. Int J Gynecol Obstet. 2014 Sep;126(3):240-3.
Pal N, Guhathakurta R, Al-Jumaily EF, Al-Mudallal NH, Muhimen NA, Al-Shaibany AA. Surgical site infection in surgery ward at a tertiary care hospital: the infection rate and the bacteriological profile. J Pharm. 2012 Sep;2(5):1-5.
Neumayer L, Hosokawa P, Itani K, El-Tamer M, Henderson WG, Khuri SF. Multivariable predictors of postoperative surgical site infection after general and vascular surgery: results from the patient safety in surgery study. J Am Coll Surg. 2007;204(6):1178-87
Black JD, de Haydu C, Fan L, Sheth SS. Surgical site infections in gynecology. Obstet Gynecol Surv. 2014;69(8):501-10.
Shah DK, Vitonis AF, Missmer SA. Association of body mass index and morbidity after abdominal, vaginal and laparoscopic hysterectomy. Obstet Gynecol. 2015;125(3):589-98.
Blikkendaal MD, Schepers EM, van Zwet EW, Twijnstra AR, Jansen FW. Hysterectomy in very obese and morbidly obese patients: a systematic review with cumulative analysis of comparative studies. Arch Gynecol Obstet. 2015;292(4):723-38.
Culver DH, Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG et al. Surgical wound infection rates by wound class, operative procedure, and patient risk index. National Nosocomial Infections Surveillance System. Am J Med. 1991;91(3):152.
Kaye KS, Schmit K, Pieper C, Sloane R, Caughlan KF, Sexton DJ, et al. The effect of increasing age on the risk of surgical site infection. J Infect Dis. 2005;191(10):56-62.
Tuuli MG, Rampersad RM, Carbone JF, Stamilio D, Macones GA, et al. Staples compared with subcuticular suture for skin closure after cesarean delivery: a systematic review and meta-analysis. Obstet Gynecol. 2011;117(3):682-90.
Mackeen AD, Berghella V, Larsen ML. Techniques and materials for skin closure in caesarean section. Cochrane Database Syst Rev. 2012;11.
Mackeen AD, Khalifeh A, Fleisher J, Vogell A, Han C, Sendecki J et al. Suture compared with staple skin closure after cesarean delivery: a randomized controlled trial. Obstet Gynecol. 2014;123(6):1169-75
Priya KS, Somasundar VM, Rajesh JG, Priya P, Muthulakshmi, Raj KM et al. Surgical site infection and incidence of mrsa using phenotypic and genotypic methods from tertiary care hospital. IOSR-JDMS. 2016;15(7):111-5.
Bhadauria AR, Hariharan C. Clinical study of post operative wound infections in obstetrics and gynaecological surgeries in a tertiary care set up. Int J Reprod Contracept Obstet Gynecol. 2016 Dec 13;2(4):631-8.
Lake AG, McPencow AM, Dick-Biascoechea MA, Martin DK, Erekson EA. Surgical site infection after hysterectomy. Am J Obstet Gynecol. 2013 Nov;209(5):490-e1.
Ahmadzia HK, Patel EM, Joshi D, Liao C, Witter F, Heine RP et al. Obstetric surgical site infections: 2 grams compared with 3 grams of Cefazolin in morbidly obese women. Obstet Gynecol. 2015;126(4):708-15.
Kawakita T, Landy HJ. Surgical site infections after cesarean delivery: epidemiology, prevention and treatment. Maternal Health Neonatol Perinatol. 2017 Dec;3(1):12.