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WORLD JOURNAL OF PHARMACEUTICAL Research Article

Maryam et al. World Journal of Pharmaceutical and Medical Research
AND MEDICAL RESEARCH ISSN 2455-3301
[Link] WJPMR

AUDIT OF SURGICAL SITE INFECTION AT NISHTAR HOSPITAL MULTAN

Dr. Maryam Saleem1, Dr. Mehvish Kiran2 and Dr. Hira Maryam*3
1
Shalamar Medical and Dental College, Lahore.
2
Shalamar Medical and Dental College, Lahore
3
Nishtar Medical University, Multan.

*Corresponding Author: Dr. Hira Maryam

Nishtar Medical University, Multan.
DOI: [Link]

Article Received on 20/09/2018 Article Revised on 10/10/2018 Article Accepted on 31/10/2018

ABSTRACT
Objective: The purpose of study was to observe surgical site infection rate at Department of Surgery, Nishtar
Hospital Multan. Study Design: It is an Observational / prospective study. Place and Duration of Study: This
study was carried out at the General Surgery Unit of Nishtar Hospital Multan, from February 2017 to November
2017. Materials and Methods: Total of 1400 patients were included. Before conduction of study Ethical review
committee permission was sought and access to patient data for follow up was obtained. Only those patients who
completed follow up for 30 days were included, patient lost to follow up or deceased were excluded. All admitted
patients undergoing elective surgery were included and categorized broadly into Abdominal Surgery, Surgery on
Thyroid and Parathyroid, Breast Surgery and Perineal Surgery. Demographic data, wound type, comorbid factors,
type of surgery, duration of hospital stay were noted on structured questionnaire. All Patient who underwent
surgery were managed according to CDC recommendation for prevention of Surgical Site Infections.[5] Wound
condition was recorded daily using ASEPSIS score during hospital stay. All patients were given pre-operative
prophylactic and postoperative antibiotics. Patients were followed up after discharge weekly for 30 days. In event
of Surgical Site Infection wound swab or pus for culture and sensitivity was obtained and appropriate antibiotics
according to sensitivity were given. Data was analyzed on SPSS version 22. Continuous variables like age and
length of stay were displayed as mean and standard deviation. Percentages were calculated for categorical variable
such as gender, type of procedure and co morbid factors. Results: A total of 1400 patients were enrolled in study
out of which 195 patients were excluded due to loss of follow up or death, the remaining 1205 patients were
studied among them 14.1% (n171) developed Surgical Site Infection (SSI). Rate of infection related to clean, clean
contaminated, contaminated and dirty wounds was 1.5%, 3%, 8% and 25% respectively in studies conducted in
developed world.[1] Rate of surgical site infection in our study in clean, clean contaminated, contaminated and dirty
wounds was 3.3%, 10.4%, 17.2% and 26.9% respectively. Conclusion: Frequency of surgical site infection in our
study was comparable to developing countries but higher than developed countries.

KEYWORDS: Surgical Site, Infection Rate, Tertiary Care Hospital.

INTRODUCTION Incisional: involving skin and subcutaneous tissue under

incision; Deep incisional primary: surgical site infection
Loss of protective barrier in form of skin makes patients
in primary incision involving muscle and fascia in a
undergoing surgery prone to infections. Surgical site
patient who has surgery performed by more than one
wound infection is one of the most common nosocomial
incisions; Deep Incisional secondary: surgical site
infection encountered in hospitals.[1] To name a few
infection involving muscle and fascia in a secondary
problems associated with surgical site infections
incision in a patient who had surgery performed by more
increasing health costs, prolonged hospital stay, re-
than one incisions; Organ/ space related surgical site
admission, loss of patient confidence in physician.[2,3]
infection: involving any part of the body opened or
Pathogens that cause SSI are acquired either
manipulated during operation.[5] Surveillance of Surgical
endogenously from the patient’s own flora or
site infection is needed to determine the burden of
exogenously from contact with operative room personnel
disease and to correct any significant deterrent to
or the environment. However, the period of greatest risk
achieve lowest rates of SSI possible keeping view of
remains the time between opening and closing the
ground realities. The purpose of our study is to assess
operating site.[3] College of Surgery National Surgical
frequency of Surgical Site infections in General Surgery
Quality Improvement Program.[4] Surgical site infection
ward and identify its risk factors.
according to CDC definitions is classified as Superficial

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Maryam et al. World Journal of Pharmaceutical and Medical Research

MATERIALS AND METHODS 713(59.17%) patients were female according to

procedure is shown in Table1. Overall infection rate in
This study was conducted in General Surgery Unit
our study across all procedure was 14.1%. Mean age of
Nishtar Hospital Multan over a period of one year, a
patients was 38.9 years ± 14.3 years. Distribution of
total of 1400 patients were included. Before conduction
wound types in Abdominal Surgery 497(41.2%), Breast
of study Ethical review committee permission was
surgery 53(4.3%), Thyroid and Parathyroid 65(5.3%)
sought and access to patient data for follow up was
and Perineal Surgery 575(47.6%) were given in Table 2.
obtained. Only those patients who completed follow up
Rate of surgical site infection in different types of
for 30 days were included, patient lost to follow up or
surgical patients was highest in perineal surgery 17.2%,
deceased were excluded. All admitted patients
followed by abdominal surgery 12.9%, breast surgery
undergoing elective surgery were included and
3.9% and lowest in thyroid parathyroid surgery 3% as
categorized broadly into Abdominal Surgery, Surgery on
shown in Table 3. This shows perineal surgery with
Thyroid and Parathyroid, Breast Surgery and Perineal
highest number of contaminated and dirty wounds had
Surgery. Demographic data, wound type, comorbid
highest rate of surgical infection and breast, thyroid
factors, type of surgery, duration of hospital stay were
parathyroid surgery has lowest rate as these surgeries
noted on structured questionnaire. All Patient who
have mostly clean wounds. Rate of surgical site infection
underwent surgery were managed according to CDC
in clean, clean contaminated, contaminated and dirty
recommendation for prevention of Surgical Site
wounds was 3.3%, 10.4%, 17.2% and 26.9%
Infections.[5] Wound condition was recorded daily using
respectively as shown in table 4. All patients were
ASEPSIS score during hospital stay. All patients were
receiving prophylactic antibiotics ceftriaxone and
given pre-operative prophylactic and postoperative
ciprofloxacin; but no statistical difference was observed
antibiotics. Patients were followed up after discharge
in surgical site infection rate.
weekly for 30 days. In event of Surgical Site Infection
wound swab or pus for culture and sensitivity was
Mean length of hospital stay for all patients was 4.7
obtained and appropriate antibiotics according to
day±2.04 days. Mean Length of hospital stay for Clean
sensitivity were given. Data was analyzed on SPSS
3.948 days, Clean Contaminated 5.714 days,
version 22. Continuous variables like age and length of
Contaminated 4.000 days and Dirty wound 5.875 days as
stay were displayed as mean and standard deviation.
shown in table 5.
RESULTS
Total of 1205 patients who were studied gender
distribution 492(40.82%) patients were male and

Table No. 1: Gender Distribution in Surgical Site Infection.

Abdominal Breast Thyroid and Perineal
S# Gender Total
Surgery Surgery Parathroid Surgery
1 Male 214(17.7%) 0 4(0.33%) 274(22.7%) 492(40.82%)
2 Female 283(23.4%) 53(4.3%) 61(5.0%) 316(26.2%) 713(59.1%)

Table No. 2: Wound Distribution in Surgical Site Infection.

Procedure
S# Wound Abdominal Breast Surgery Thyroid and Perineal
Total N
Surgery N(%) N(%) Parathroid N(%) Surgery N(%)
1 Clean 0 53(4.3%) 65(5.3%) 0 118
Clean
2 497(41.2%) 0 0 0 497
Contaminated
3 Contaminated 0 0 0 575(47.6%) 575
4 Dirty 0 0 0 16(1.3%) 16
Total 497(41.2%) 53(4.3%) 65(5.3%) 591 (48.9) 1205

Table No. 3: Distribution of Sites in Surgical Site Infection.

Surgical Sites Abdominal Breast Thyroid and Perineal
Infection Surgery N(%) Surgery N(%) Parathyroid N(%) Surgery N(%)
None 436(87%) 51(96.2%) 63(96.9%) 488(82.7%)
Present 65(12.9%) 2(3.9%) 2(3%) 102(17.2%)

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Maryam et al. World Journal of Pharmaceutical and Medical Research

Table No. 4: Distribution of Wounds in Surgical Site Infection.

Type of Wound
Surgical Site Infection Clean Clean Contaminated Contaminated Dirty
None 114(96.6%) 436(89.5%) 475(82.7%) 19(73%)
Present 4(3.3%) 51(10.4%) 99(17.2%) 7(26.9%)
Total 118 487 574 26

Table No. 5: Mean Duration of hospital stay (days) in different wounds.

Wound Mean Duration (days) No. of cases Std. Deviation

Clean 3.948 116 1.0701
Clean Contaminated 5.714 497 2.7575
Contaminated 4.000 574 .0000
Dirty 5.875 18 4.0311
Total 4.728 1205 2.0449

DISCUSSION No statistical difference was noted when surgical site

infection rate was compared with age and co morbid
Surgical site infection is one of the biggest problems in
factors.[14] Cohen et al identified risk factors for surgical
healthcare industry effecting surgical and it costs 1.4719
site infections as estimated blood loss over 1 litre
billion Euros.[6] Rate of Surgical site infection has been
(P=0.017), previous Surgical site infection (P=.012) and
progressively decreasing in developed world with rates
diabetes (P=0.050)[15] and similar trend has been noted in
reported as low as 2.6%.[7] Rates of infection in
our study. Duration of procedure and BMI has also been
laparoscopic procedures Cholecystectomy, colonic
established as independent risk factors.[16] Surgical site
surgery appendectomy and gastric surgery are even
infection risk score calculation by Walraven et al have
lower 0.69%, 4.32%, 1.37%, 2.71%.[8,9] Rates of
included patient factors like smoking BMI, operative
infection in Pakistani tertiary care hospital at Karachi
factors like surgical urgency; increased ASA class;
has been reported to be 7.32%.[10] Prolonged
longer operation duration; infected wounds; general
preoperative hospital stay was found to be associated
anaesthesia; performance of more than one procedure;
with higher rate of infection. Prolonged preoperative
CPT score, and co morbidities like peripheral vascular
hospital stay leads to colonization with antimicrobial
disease, metastatic cancer, chronic steroid use, recent
resistant micro-organisms and itself directly affects
sepsis in their predictive score.[17]
patient’s susceptibility to infection either by lowering
host resistance or by providing increased opportunity for
CONCLUSION
ultimate bacterial colonization. Comparative analysis of
studies reporting surgical site infections in Brazil 5.1% Frequency of Surgical site infections is similar to
Philippines 7.8% and Nepal 7.3% are lower than any developing countries but very much higher than
hospital in Pakistan this proves that more is to be done in developed countries with poor compliance to
prevention, risks assessment and management.[11] When sterilization protocols, unabated use of antibiotics, and
compared to other hospitals in our country reported rates poor socioeconomic status of patients. No apparent
of Surgical site infection in our study is higher surveillance protocols of SSI like American College of
(14.1%).[10] Causative factors identified in studies Surgery National Surgical Quality Improvement
conducted in our country are indiscriminate use of Program and absence of infectious disease specialist at
antibiotics leading to growth of resistant organisms, poor most tertiary care public sector hospitals, result in higher
nutritional status of patient leading to poor wound Surgical site infection. Areas in need of attention are
healing, absence of barrier nursing and inadequate establishment of surveillance protocols and reporting
sterilization. Patient overcrowding in public sector system. Establishment of Clinical audit and review,
hospitals leads to cross infection.[12] The rate of SSI also judicious use of antibiotics.
varies from surgeon to surgeon. The skill and experience
of surgeon directly affects the degree of contamination Conflict of Interest: The study has no conflict of
of the surgical site through breaks in technique or interest to declare by any author.
inadvertent entry in to a viscous. The skill of surgeon
also affects the condition of surgical site and therefore its
resistance to infection. In our study the rate of SSI was
19.6% in operations performed by junior doctors
compared to rate in operations performed by senior
consultants (12.9%). Anvikar A.R. 2 also reported higher
rate of infection in operations performed by junior
doctors.

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Maryam et al. World Journal of Pharmaceutical and Medical Research

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