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Global surgical site infection toll affects one in 10 patients

Overuse of antibiotics before and after surgery to blame, international study finds

Caroline White

Wednesday, 14 February 2018

More than one in 10 (12%) patients around the world develops a surgical site infection within 30 days of gastrointestinal surgery, finds a study* of more than 12,500 people in 66 countries, published in The Lancet Infectious Diseases.

Cases of surgical site infection vary depending on a country’s level of development, with patients in high-income countries least at risk, and those in low-income countries most at risk, the findings show.

Worryingly, more than one in five (22%) of these infections were resistant to the antibiotics given before surgery to ward off infections.

“These findings begin to characterise the relationship between surgical site infections and global antimicrobial resistance,” says Dr Ewen Harrison, NIHR Unit on Global Surgery at the University of Edinburgh.

“Worldwide, large amounts of antibiotics were consumed to prevent and treat surgical site infections, yet in a fifth of cases the causative microorganism was resistant to the pre-surgery antibiotics given, and this increased to one in three cases in low-income countries.

“This high prevalence illustrates a potentially important area for improvement worldwide, and reducing surgical site infections will help to ensure safe and essential surgery around the world.”

The researchers tracked 12,539 patients from 343 hospitals in 15 countries in Africa, 16 in Asia, 22 in Europe, eight in North America, one in Oceania, and four in South America to see if they developed a surgical site infection within 30 days of their emergency or planned procedure.

More than half (59%; 7,339 people) were from 30 high-income countries; around a third (31%; 3918) came from 18 middle-income countries, and one in 10 (1,282) were from 18 low-income countries.

Just under 2% (235/12539) of the patients died within 30 days of their surgery, with the highest number of cases in low-income countries (4.8%, 61/1282).

The most common types of surgery were gall bladder or appendix removal. Half of the patients (49%) had emergency surgery.

Some 12% (1538/12539) of all the patients developed a surgical site infection within 30 days. But incidence varied depending on a country’s level of development: 9% (691/7339) of patients in high-income countries, 14% (549/3918) in middle-income countries, and 23% (298/1282) in low-income countries. This pattern remained even after taking account of different patient characteristics, diseases, contamination levels, procedures, and hospitals in low-income countries.

Patients with a surgical site infection were more likely to die than those without: 4.7% (73/1538) compared with 1.5% (162/11001). They were also more likely to have another infection and need further surgery. And hospital stays were three times longer on average (seven days vs two days).

Microbiology results were available for 610 patients with a surgical site infection: 22% (132 people) of cases were resistant to the antibiotics given before surgery to prevent infections.

Once again, incidence varied depending on a country’s income level: patients in low-income countries were most at risk (36%, 46/128), with those in high-income countries least at risk (17%, 49/295).

The researchers found signs of antibiotic overuse in low-income countries where patients were more likely to be given these drugs before and after surgery than patients in middle- and high-income countries (96%, 87%, and 88% of patients, respectively, before surgery; and 86%, 80% and 46%, respectively, afterwards).

The researchers acknowledge that they were unable to track all patients for 30 days after surgery, so some cases might have been missed; but the size of the study compensates for that, to some extent, they say.

In a linked comment, Dr Robert Sawyer, Western Michigan University Homer Stryker M D School of Medicine, USA, writes: “To document surgical site infections 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 postoperative infections and their associated morbidity and mortality.

“The GlobalSurg Collaborative clearly describes the magnitude of the problem of surgical site infections in all care settings but particularly in resource-stressed environments. Although the idea that a surgical site infection is just a surgical site infection is prevalent, it is now well known that the cost of a surgical site infection in terms of mortality, morbidity, healthcare costs, and loss of productivity is enormous.”

*Bhangu, Aneel et al. Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study. The Lancet Infectious Diseases, Volume 0, Issue 0, 13 February 2018.

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