Clinical Leadership, Evaluation, and Action Network for surgical site infection control: protocol enhancement in Sudan

Highlights

• •National multicenter audit of surgical site infection prevention across 10 Sudanese hospitals.
• •Audit–feedback model significantly improved perioperative adherence.
• •Gains seen in glycemic control, antibiotics, sterility, and surveillance.
• •Infection prevention and control systems strengthened: training, safety culture, data-driven monitoring.
• •Demonstrates scalable quality-improvement model for low-resource settings.

Graphical abstract

Abstract

Objectives

Surgical site infections (SSIs) represent the most prevalent healthcare-associated illnesses in developing countries. As a frequent and sometimes severe complication of surgery, SSIs contribute substantially to the global burden of healthcare-associated infections, both historically and in contemporary practice.

Methods

A national, multicenter clinical audit with a two-cycle before-and-after design was conducted in 10 public teaching hospitals. Perioperative care providers completed a structured questionnaire aligned with World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) SSI prevention guidelines. After the baseline assessment, targeted feedback and educational interventions were implemented, followed by a re-audit after 2 months. Adherence rates were compared using chi-square tests (P < 0.05).

Results

Analysis included 600 responses (300 per cycle). Significant improvements were observed in most domains. Preoperative practices improved in glycemic control (83-96%), methicillin-resistant Staphylococcus aureus (MRSA) decolonization (23-51%), and antimicrobial prophylaxis compliance (all P < 0.001). Intraoperative adherence increased for sterile technique (89%-97%), normothermia (78%-86%), glycemic control (80%-90%), oxygen therapy (81%-92%), and surgical site protection (P < 0.01). Postoperative improvements were noted in SSI surveillance (58%-86%) and dressing protocols (86%-94%) (P ≤ 0.001). Strengthening of infection prevention and control (IPC) systems was evident, with increases in training (30%-68%), bundle implementation (35%-57%), safety culture (35%-60%), and data-driven monitoring (31%-59%) (all P < 0.001).

Conclusion

Strengthening IPC systems and adherence to SSI prevention measures was achieved through a structured audit-feedback approach. This model provides a practical pathway for advancing surgical quality in resource-limited settings.

Introduction

In underdeveloped nations, surgical site infections (SSIs) are the most common healthcare-associated illnesses [1]. The term ``surgical wound infection'' has been replaced by ``surgical site infection,'' a nomenclature adopted by the USA Centers for Disease Control and Prevention (CDC) in 1992. The CDC classifies SSIs as superficial (affecting skin and subcutaneous tissue within 30 days post-surgery), deep (involving fascia and muscles, within 30 days or up to 1 year if a foreign body is implanted), or organ/space (arising within 30 days or up to 1 year after implantation, in a nearby organ or cavity) [2].

SSIs affect 5%-10% of hospitalized patients in affluent nations, demonstrating their prevalence and the necessity of stringent infection control protocols [3]. The World Health Organization (WHO) recommendations for SSI prevention emphasize the need to wear sterile gloves correctly and practice strict hand hygiene. Comprehensive instructions for appropriate glove wearing and infection control procedures are also available from the CDC [4].

The reality in operating theaters and surgical wards across Sudan is sobering. SSI rates are persistently high, contributing significantly to patient morbidity, prolonged hospital stays, increased antibiotic resistance, avoidable mortality, and substantial financial costs. While the core principles of SSI prevention (encompassing preoperative, intraoperative, and postoperative care) are well established globally by bodies like the WHO and the CDC, their consistent application within the unique context of Sudan's diverse healthcare facilities facing challenges like resource limitations, staffing issues, and infrastructure constraints is unknown and likely variable. Without a clear, evidence-based understanding of the current state of SSI protocol implementation, efforts to improve are fragmented and lack national coordination. This audit aims to systematically assess and document SSI protocol implementation across diverse Sudanese healthcare settings, addressing this critical gap.

Methods

Audit design

A national, multicenter clinical audit was undertaken to assess adherence to key, evidence-based measures for prevention of SSI. The audit followed a two-cycle before-and-after design: an initial cycle to document baseline practice, followed by targeted feedback and educational interventions, and then a re-audit using the same tool to evaluate change in adherence to predefined standards.

Setting

The audit included 10 public teaching hospitals across eight Sudanese states (Gezira, River Nile, Kassala, Red Sea, White Nile, North Kordofan, Gadarif, and Northern State), ensuring geographic and healthcare system diversity. Participating sites comprised Port Sudan Teaching Hospital, Rabak Teaching Hospital, Alhasahisa Teaching Hospital, Gadarif Teaching Hospital, El Obeid Teaching Hospital, Wad Madani Teaching Hospital, Kassala Teaching Hospital, Aldamer Teaching Hospital, Merowe Teaching Hospital, and Atbara Teaching Hospital. Each hospital appointed a local surgical or infection prevention and control (IPC) lead to coordinate the dissemination of tools, data collection, and intervention delivery.

Participants and sampling

The audit population comprised doctors involved in perioperative care, including specialist surgeons, registrars, and other theater-based clinicians working in the selected hospitals. Within each hospital, a pragmatic, convenience sampling approach was used. Local coordinators circulated the survey link through departmental and professional communication channels to capture a broad mix of specialties and seniority levels among doctors routinely engaged in perioperative care. Participation was entirely voluntary, and responses were anonymous.

Audit tool and standards

Data were collected using a structured, self-administered online questionnaire. The instrument was developed from current international SSI prevention guidance, primarily the WHO SSI prevention guidelines and associated perioperative recommendations, supplemented by relevant CDC standards [[5], [6], [7]].

Items were grouped into four domains, aligned with the structure of the results:

• •Preoperative patient preparation and antimicrobial prophylaxis: glycated hemoglobin (HbA1c) assessment and perioperative glycemic control, preoperative infection screening, methicillin-resistant Staphylococcus aureus (MRSA) screening and decolonization, preoperative bathing, timing of prophylactic antibiotics, selection of agent, and discontinuation within 24 h.
• •Intraoperative practice: skin preparation, hair removal practices, maintenance of aseptic technique and a sterile field, intraoperative temperature management, intraoperative glycemic control, oxygen therapy, use of antiseptic incise drapes, and measures for surgical site protection.
• •Postoperative wound care and monitoring: dressing protocols, scheduled wound assessment, and SSI surveillance at defined time points, and alignment of therapeutic antibiotic use with stewardship principles.
• •Clinical leadership and systems/IPC infrastructure: multidisciplinary IPC training, implementation of SSI prevention bundles, safety culture and incident reporting, verification of terminal operating room cleaning, and use of SSI data for feedback and quality improvement.

For each item, respondents indicated whether the specified standard was routinely met in their own practice or within their institution, allowing adherence for each standard to be expressed as a proportion of respondents who answered affirmatively.

Data collection procedures

First cycle (baseline)

In the baseline cycle, the survey was hosted on a secure online platform. The electronic link was disseminated by local hospital coordinators to roughly 30 eligible doctors per site, primarily via existing institutional and professional messaging channels. Doctors completed the questionnaire independently using personal or workplace devices. Data collection continued for a predefined period until the target sample size for each hospital and state was achieved.

Following the closure of the first cycle, responses were exported from the online platform, screened for completeness and consistency, and prepared for analysis. Baseline adherence to each standard and domain was then summarized at hospital, state and national levels.

Intervention and feedback

On completion of the first-cycle analysis, tailored feedback was provided to all participating hospitals. Results were presented during structured sessions led by the central audit team in collaboration with local coordinators. These sessions reviewed performance across the four domains, highlighted areas of strong and weak adherence, and facilitated agreement on feasible improvement actions (e.g. tightening the timing of prophylactic antibiotics, reinforcing preoperative bathing instructions, standardizing dressing protocols, strengthening SSI surveillance documentation, and expanding multidisciplinary IPC training and bundle implementation). Key points from the sessions were reinforced through additional educational activities and visual materials (including posters) displayed in operating theaters and surgical wards.

Second cycle (re-audit)

A 2-month interval was selected as a pragmatic quality-improvement interval to allow participating hospitals sufficient time to receive feedback, conduct educational activities, disseminate visual reminders, and implement feasible changes in perioperative practice while maintaining the audit cycle within a practical timeframe. The interval was intended to assess early changes in reported adherence rather than to establish sustained long-term behavioral or clinical outcomes. The same online questionnaire, with identical wording and response options, was redistributed to doctors in the same hospitals using the same dissemination routes. This ensured direct comparability between cycles. Reminder messages were issued to maximize completion. Data collection again continued until 300 responses had been obtained, preserving the same distribution by state and hospital as in the baseline cycle.

Because the questionnaire was anonymous and no personal identifiers were collected, responses could not be individually linked across the two audit cycles. Accordingly, the analysis compared aggregate adherence proportions between the two cycles rather than paired responses from the same participants. The same questionnaire, participating hospitals, dissemination channels, and sampling targets were maintained across cycles to maximize comparability.

Data management and analysis

Survey data from both cycles were exported into a statistical software environment for analysis. After excluding incomplete or internally inconsistent responses, frequencies and percentages (n, %) were calculated for adherence to each individual item in each domain. Adherence across the four domains was similarly summarized at the national level and, where appropriate, by state and hospital.

To examine changes in adherence between cycles, proportions in the first and second cycles were compared using Pearson’s chi-square test. A P < 0.05 was taken to indicate statistical significance. Results are reported in tabular form for each domain, alongside a narrative synthesis of the main patterns of improvement.

Ethical considerations

The audit formed part of ongoing national efforts to improve surgical quality and infection prevention. Necessary approvals and administrative clearances were obtained from relevant health authorities and institutional leadership prior to data collection. Participation by doctors was voluntary; completion and submission of the online questionnaire were taken as implied consent. No patient-identifiable information was collected, and all clinician responses were anonymized before analysis. Findings are presented only in aggregate form (hospital, state, and national), with the explicit aim of supporting service improvement rather than appraising individual clinicians. This study complies with the principles laid down in the Declaration of Helsinki.

Results

The national clinical audit in Sudan evaluated SSI prevention practices across two cycles; a total of 600 data points were included, comprising 300 in the first cycle (pre-intervention) and 300 in the second (post-intervention).

This study assessed adherence to and the effectiveness of SSI management protocols. Based on the WHO Surgical Safety Checklist and the WHO/CDC SSI prevention guidelines, 10 teaching hospitals across eight Sudanese states were included. Gezira and River Nile states each accounted for 20% of audited responses, while the other states each contributed 10%, as shown in Table 1. Each participating hospital contributed an equal number of responses in both audit cycles.

Table 1.

Distribution of the participants by states and hospitals.

Characteristic	First cycle, N = 300a	Second cycle, N = 300a	Overall, N = 600a
State
Gezira State	60 (20%)	60 (20%)	120 (20%)
River Nile State	60 (20%)	60 (20%)	120 (20%)
Kassala State	30 (10%)	30 (10%)	60 (10%)
Red Sea State	30 (10%)	30 (10%)	60 (10%)
White Nile State	30 (10%)	30 (10%)	60 (10%)
North Kordofan State	30 (10%)	30 (10%)	60 (10%)
Gadarif State	30 (10%)	30 (10%)	60 (10%)
Northern State	30 (10%)	30 (10%)	60 (10%)
Hospital
Port Sudan Teaching Hospital	30 (10%)	30 (10%)	60 (10%)
Rabak Teaching Hospital	30 (10%)	30 (10%)	60 (10%)
Alhasahisa Teaching Hospital	30 (10%)	30 (10%)	60 (10%)
Gadarif Teaching Hospital	30 (10%)	30 (10%)	60 (10%)
El Obeid Teaching Hospital	30 (10%)	30 (10%)	60 (10%)
Wad Madani Teaching Hospital	30 (10%)	30 (10%)	60 (10%)
Kassala Teaching Hospital	30 (10%)	30 (10%)	60 (10%)
Aldamer Teaching Hospital	30 (10%)	30 (10%)	60 (10%)
Merowe Teaching Hospital	30 (10%)	30 (10%)	60 (10%)
Atbara Teaching Hospital	30 (10%)	30 (10%)	60 (10%)

^an (%).

In Table 2 and Figure 1, notable improvements are seen in most preoperative characteristics between the two audit cycles. For example, glycemic control increased significantly from 83% in the first cycle to 96% in the second cycle (P < 0.001). Compliance with MRSA decolonization increased from 23% to 51% (P < 0.001), and preoperative bathing with soap or antiseptics also improved significantly, rising from 35% to 62% (P < 0.001). Antimicrobial prophylaxis practices substantially surged as well, including correct timing of antibiotic administration (76% vs 88%, P < 0.001), appropriate agent selection (74% vs 89%, P < 0.001), and documentation of intraoperative redosing and discontinuation (56% vs 77%, P < 0.001). While slight improvements are observed in the remaining items, it is important to note that MRSA decolonization still needs further improvement, given its critical role in SSI prevention. Therefore, we suggest more emphasis on this matter in future audits or interventions.

Table 2.

Preoperative practice (patient preparation and screening as well as antimicrobial prophylaxis) change between the first and second cycles, national audit, Sudan.

Characteristic	First cycle N = 300a	Second cycle N = 300a	P-valueb
Glycemic Control: HbA1c measured for patients with diabetes (≤7% recommended for elective surgery)	250 (83%)	288 (96%)	<0.001
Infection Screening: active infections (e.g. UTI, skin/soft tissue) identified and treated before surgery	274 (91%)	291 (97%)	0.003
MRSA Decolonization: high-risk patients (e.g. prior MRSA, ICU admission) screened and decolonized with intranasal mupirocin + chlorhexidine bathing	68 (23%)	154 (51%)	<0.001
Preoperative Bathing: patient instructed to shower with soap or antiseptic (e.g. chlorhexidine) ≥1 time the night before/day of surgery	105 (35%)	187 (62%)	<0.001
Timing: systemic antibiotic administered within 60-120 min before incision (vancomycin/fluoroquinolones: within 120 min)	228 (76%)	263 (88%)	<0.001
Selection: agent selected according to procedure type, local resistance patterns, and patient allergies	221 (74%)	267 (89%)	<0.001
Discontinuation: intraoperative redosing documented (if procedure duration > half-life of antibiotic or blood loss >1500 mL), and prophylaxis stopped within 24 h	169 (56%)	231 (77%)	<0.001

HbA1c, glycated hemoglobin A1c; ICU, intensive care unit; MRSA, methicillin-resistant Staphylococcus aureus; UTI, urinary tract infection.

^aPearson’s chi-square test, n (%).

Figure 1.

Compliance with SSI prevention protocols in the preoperative phase.

MRSA, methicillin-resistant Staphylococcus aureus; SSI, surgical site infection.

Table 3 and Figure 2 show intraoperative practices. Adherence to skin antisepsis and hair removal was high, with no significant difference between cycles (97% vs 98%, P = 0.4; 65% vs 71%, P = 0.14).

Table 3.

Intraoperative practice (operative environment and technique; physiological management; and instrument and wound management) change between the first and second cycles, national audit, Sudan.

Characteristic	First cycleN = 300a	Second cycle N = 300a	P-valueb
Skin Preparation: antiseptic (alcohol-based chlorhexidine or povidone-iodine) applied using FDA-approved method	292 (97%)	295 (98%)	0.4
Hair Removal: no hair removal unless interfering with surgery; if required, electric clippers used	196 (65%)	213 (71%)	0.14
Sterile Field Maintenance: surgical team compliance with aseptic technique (hand hygiene, glove/gown changes) documented	267 (89%)	290 (97%)	<0.001
Normothermia: patient core temperature ≥36°C monitored and maintained (forced-air warming devices used)	233 (78%)	258 (86%)	0.008
Glycemic Control: blood glucose maintained at 110-150 mg/dL (noncardiac surgery)	240 (80%)	270 (90%)	<0.001
Oxygen Therapy: fraction of inspired oxygen (FiO₂) at 80% during intubation and 2-6 h postoperatively (conditional recommendation)	242 (81%)	275 (92%)	<0.001
Antiseptic Incise Drapes: iodophor-impregnated drapes used if indicated	238 (79%)	275 (92%)	<0.001
Surgical Site Protection: laparoscopic techniques preferred where feasible; passive wound protectors used in open surgery	261 (87%)	285 (95%)	<0.001

FDA, Food and Drug Administration; FiO₂, fraction of inspired oxygen.

^aPearson’s chi-square test, n (%).

Figure 2.

Compliance with SSI prevention protocols in the intraoperative phase.

SSI, surgical site infection.

In contrast to other areas with high adherence, several intraoperative domains improved. Compliance with the sterile field rose from 89% to 97% (P < 0.001). Normothermia maintenance improved from 78% to 86% (P < 0.008), and glycemic control increased from 80% to 90% (P < 0.001).

The use of a fraction of inspired oxygen of 80% during intubation and after surgery rose from 81% to 92% (P < 0.001). Use of iodophor-impregnated incise drapes increased from 79% to 92% (P < 0.001), and compliance with site protection measures, such as laparoscopic methods when possible and wound protectors in open surgery, improved from 87% to 95% (P < 0.001).

In Table 4 and Figure 3, postoperative wound care and monitoring practices showed noticeable improvements. Compliance with recommended sterile dressing protocols increased from 86% in the first cycle to 94% in the second cycle (P = 0.001). Additionally, SSI surveillance showed marked improvement, with incision-site assessments at recommended time points increasing from 58% to 86% (P < 0.001). On the other hand, improvement in antibiotic stewardship practices, where therapeutic antibiotics are administered for diagnosed SSI, reached statistical significance (70% vs 78%, P = 0.025).

Table 4.

Postoperative wound care and monitoring practice change between the first and second cycles, national audit, Sudan.

Characteristic	First cycle N = 300a	Second cycle N = 300a	P-valueb
Dressing Protocol: sterile dressing maintained for 24-48 h; no topical antibiotics applied	258 (86%)	282 (94%)	0.001
SSI Surveillance: incision site assessed for redness, discharge, or pain at 24 h, 72 h, and 30 days (for implants)	175 (58%)	259 (86%)	<0.001
Antibiotic Stewardship: therapeutic antibiotics only administered for diagnosed SSI (cultures obtained)	211 (70%)	235 (78%)	0.025

SSI, surgical site infection.

^aPearson’s chi-square test, n (%).

Figure 3.

Compliance with SSI prevention protocols in the postoperative phase.

SSI, surgical site infection.

Clinical leadership and systems supporting SSI prevention are presented in Table 5 and Figure 4. Annual multidisciplinary IPC training increased significantly from 30% to 68% (P < 0.001). Compliance with evidence-based surgical bundles improved from 35% to 57% (P < 0.001). Safety culture, including staff empowerment to report breaches and conducting monthly SSI case reviews, increased from 35% to 60% (P < 0.001). Compliance with operating room (OR) cleaning verification improved from 47% to 73% (P < 0.001); also, the use of data-driven SSI monitoring and feedback increased from 31% to 59% (P < 0.001).

Table 5.

Clinical leadership and systems (infection prevention and control [IPC] infrastructure as well as environmental and auditing standards)` before and after the intervention, national audit, Sudan.

Characteristic	First cycle N = 300a	Second cycle N = 300a	P-valueb
IPC Training: multidisciplinary team (surgeons, nurses, anesthetists) trained in SSI prevention protocols annually	89 (30%)	204 (68%)	<0.001
Surgical Bundle Compliance: hospital implements ≥1 evidence-based bundle (e.g. WHO 29 recommendations, 7S Bundle: Safe Operating Room Practices, Screen - MRSA, MSSA and Risk Factors, Shower (Preoperative Cleansing and Decolonization), Dkin Antisepsis, Surgical Irrigation, Sutures - Antibacterial Coated with Triclosan, Skin Incisional Protection ) with >90% adherence	105 (35%)	172 (57%)	<0.001
Safety Culture: staff empowered to report breaches via anonymous system; leadership conducts monthly SSI case reviews	105 (35%)	180 (60%)	<0.001
OR Cleaning Verification: terminal cleaning compliance monitored using CDC/WHO checklists	141 (47%)	219 (73%)	<0.001
Data-Driven Improvement: SSI rates stratified by procedure, surgeon, and risk index; quarterly feedback to departments	93 (31%)	178 (59%)	<0.001

CDC, Centers for Disease Control and Prevention; IPC, infection prevention and control; OR, operating room; SSI, surgical site infection; WHO, World Health Organization.

^aPearson’s chi-square test, n (%).

Figure 4.

Compliance with SSI prevention protocols in clinical leadership and systems.

IPC, infection prevention and control; SSI, surgical site infection.

One of the implemented changes was putting posters in the surgical staff office, the operating rooms, and the doctors' office. The poster is shown in Figure 5.

Figure 5.

Sample of the posters distributed in participating hospitals as part of the intervention between the first and second cycles.

WHO, World Health Organization.

Discussion

This national multicenter clinical audit demonstrated an increase in reported adherence to several evidence-based SSI prevention practices following a structured audit–feedback intervention. Improvements occurred in clinical procedures before, during, and after surgery, as well as in IPC leadership, surveillance infrastructure, and safety culture. These data show that reducing SSIs in fragile health systems requires investing in both frontline clinical optimization and system-level governance reforms together.

Preoperative optimization as a foundation for SSI prevention

During the preoperative phase, the assessment of glycemic control in patients with diabetes markedly improved between cycles. Optimized perioperative glycemic management is recognized as a critical strategy for reducing SSIs, as hyperglycemia impairs immune function and wound healing. Systematic reviews demonstrate that improved blood glucose control reduces the occurrence of SSIs in surgical patients, particularly those with diabetes, highlighting the clinical significance of this finding [8].

The timing and appropriateness of antimicrobial prophylaxis have improved a lot. For surgical antimicrobial prophylaxis to work, it needs to be given at the right time to make sure that the tissue levels of the drug are high enough to kill bacteria at the incision site (within 60 min for most antibiotics and within 120 min for agents like vancomycin) [5,9]. Recent research emphasizes that accurate timing and dosing, particularly regular administration within the ideal window, substantially lower the risk of SSIs across surgical settings [10]. Despite things getting better, the practice of using antibiotics for a long time after surgery was still a problem. This is important because WHO guidelines usually recommend not extending prophylaxis beyond the perioperative period, as it does not help and can worsen antimicrobial resistance [5].

At the national level, MRSA screening and decolonization improved but remained inadequate. Guideline committees recommend targeted screening and decolonization for patients at elevated risk of S. aureus SSIs, especially those undergoing orthopedic and cardiothoracic procedures, based on substantial evidence that decolonization lowers SSI rates [11,12]. Preoperative bathing improved, although not everyone followed it. Although comprehensive evidence regarding the impact of bathing on SSI rates is inconclusive, established guidelines advocate for a minimum of one preoperative shower or bath with soap (either plain or antimicrobial) as a standard therapeutic practice to mitigate skin bacterial colonization prior to surgery [6,13].

The recorded improvements confirm the effectiveness of clinical audit and feedback as quality enhancement strategies in resource-limited settings. This aligns with international guidelines suggesting that structured observation, feedback, and benchmarking may improve adherence to SSI preventive methods, particularly in resource-limited environments [14]. The varying rates of improvement across different metrics suggest that practices requiring minimal additional resources (e.g. glycemic control assessment, prophylaxis timing) show faster enhancement than those needing comprehensive infrastructural changes (e.g. MRSA decolonization protocols or patient self-management strategies). These patterns indicate the need for tailored implementation frameworks that integrate clinical audits with targeted systems enhancements.

Intraoperative practice: translating standards into action

Adherence to sterile field management improved significantly throughout the cycles and became almost universal. To prevent SSIs, it is important to maintain aseptic technique throughout surgery. This includes washing your hands properly, changing your gloves and gowns on time, and maintaining a sterile field. The reported improvement shows that surgical teams are more aware of their surroundings and better at following standard operating procedures after getting audit remarks. Similar outcomes have been demonstrated in other low- and middle-income settings, where targeted audits and collaborative efforts have led to measurable improvements in intraoperative discipline [1]. Conversely, practices for skin preparation and hair removal showed very minimal, statistically insignificant alterations. Baseline adherence to proper antiseptic skin preparation was already elevated, perhaps indicative of the prevalent use of alcohol-based antiseptics as a normative practice. Hair-removal practices were still not ideal, and in some situations, people still relied on unnecessary hair removal. This is in line with studies from around the world that show hair removal habits are deeply ingrained and hard to modify without clear institutional policy and staff retraining [5,15].

There were considerable advances in intraoperative physiological optimization, especially in keeping normothermia, managing blood sugar levels, and giving extra oxygen. Maintaining a normal body temperature reduces the risk of SSIs by supporting the immune system and oxygenating tissues. The heightened implementation of temperature monitoring and warming protocols in the second cycle indicates enhanced perioperative coordination and a deeper comprehension of normothermia as a manageable risk factor for SSIs [5,16]. Strict glucose management reduces the risk of infection by mitigating immunological dysfunction and endothelial damage. This is especially true for those with diabetes and those who are critically unwell. The big improvement is startling, showing how hard it is to monitor glucose levels when resources are limited. It also shows how easy it is to implement education- and audit-based accountability to deliver excellent physiological therapies [8,17]. The increased adherence to treatment with a high fraction of inspired oxygen (FiO₂) signifies a growing acceptance of conditional WHO recommendations. The evidence for increased FiO₂ is unclear; recent meta-analyses show that carefully administered oxygen supplementation can lower the incidence of SSIs in some patient groups [5,18]. The improvement observed in this audit indicates the effective application of refined guideline recommendations in clinical practice.

One of the most noticeable changes was the use of sterile incise drapes and protective measures for the surgical site, such as wound protectors and a preference for laparoscopic approaches where possible. Wound protection devices have been demonstrated to markedly decrease SSI incidence in clean-contaminated and contaminated surgeries by restricting bacterial transfer to the incision site [19,20]. The rising usage of laparoscopic procedures, when possible, shows that more people are aware of minimally invasive surgery as a way to lower the risk of SSIs. Minimally invasive techniques reduce tissue damage, exposure to environmental pollutants, and wound size, all of which are associated with lower SSI incidence. Even though not everyone in Sudan has access to laparoscopic equipment, the improvement we saw suggests that better case selection and more effective use of current resources are more likely than a broader increase in technology.

Not all improvements in reported adherence to intraoperative practices occurred to the same extent. This finding suggests that some practices may be more readily modified than others within a short audit–feedback cycle. Reported adherence improved more substantially for practices such as aseptic technique and intraoperative glycemic monitoring following the feedback intervention. Awareness and everyday behaviors are the main things that affect those steps. But certain things take longer, including ensuring hair removal is done correctly or providing warmers for every patient. To make such changes happen, the entire hospital needs policies, the necessary tools, and ongoing support from management. This is not something that only happened to us. Research conducted globally on the prevention of SSIs consistently finds that feedback is insufficient without supporting processes and accountability [1,21].

Postoperative care and surveillance: closing the loop

There was a big improvement in following standard postoperative dressing techniques over time between audit cycles. It is standard practice worldwide to keep bandages clean for 24-48 h and avoid using topical antibiotics. These practices reduce the risk of infection in a wound and of administering medications incorrectly. This improvement is probably due to a better understanding of what to do after surgery and better teamwork between the surgical and nursing teams in sharing evidence-based wound care procedures [5,22]. The most significant enhancement was noted in SSI surveillance methodologies. The frequency of routine postoperative wound assessments at standardized intervals significantly increased during the second cycle. Efficient SSI monitoring is crucial for prompt detection, appropriate intervention, and precise assessment of SSI prevalence, especially in environments where patients may be released prematurely or become lost to follow-up. Enhanced surveillance procedures indicate a greater recognition of SSI as a quantifiable quality metric rather than an unavoidable surgical complication [1].

Postoperative antibiotic use, on the other hand, improved only slightly and statistically meaningful. This aligns with studies from around the world: changing how antibiotics are prescribed is tough. Old habits are hard to break; there is often uncertainty about whether an infection is brewing, and many clinicians worry about what happens if they do not prescribe. In places already stretched thin by conflict or limited resources, the lack of lab services makes it even harder to tell when antibiotics are truly needed [5]. What this tells us is that better antibiotic use will not happen on its own. It has to be part of a broader effort that links infection tracking, microbiology support, and dedicated stewardship programs.

Reported adherence increased across all five clinical leadership and IPC-system indicators assessed in the audit, including multidisciplinary IPC training (30% to 68%), surgical bundle implementation (35% to 57%), safety-culture criteria (35% to 60%), OR-cleaning verification (47% to 73%), and data-driven SSI monitoring and feedback (31% to 59%). These findings indicate increased reported adherence to the predefined system-level audit criteria following the intervention, although they do not establish changes in actual institutional culture or patient outcomes. Education like this is what makes lasting change possible, and research consistently shows it strengthens adherence to SSI prevention bundles [23]. We also saw clear improvement in the consistency with which those evidence-based bundles were applied. By grouping several high-impact practices into a single protocol, bundles help reduce variation and make care more predictable. The increase in compliance indicates that the institution is becoming more adept at quality improvement and that feedback from the audit is being actively translated into real-world clinical practice [24].

Reported adherence to the audit criteria related to safety culture increased from 35% to 60% between the two cycles. These criteria included staff empowerment to report breaches through an anonymous system and leadership involvement in regular SSI case reviews. That kind of shift in culture is important. Studies show that a strong safety culture always leads to fewer infections and helps quality improvements persist [25]. Regular SSI morbidity reviews are clear evidence that infections are no longer considered as unavoidable problems, but as problems that can be avoided and should be dealt with at the top.

There is a real difference in how operating rooms are cleaned and watched over, and that is a big deal. When environmental hygiene improves, it does not just check a box; it also reduces the number of germs and strengthens aseptic work during surgery. The fact that WHO and CDC checklists are now part of daily life shows that the hospital is not simply saying it follows international standards; it is actually putting them into practice [26]. The most exciting change might be that data is finally being used. For a long time, infection rates were just figures on a computer screen. Now, teams are digging deeper and using that information to make real-time changes. That kind of targeting makes feedback useful, not automatic. When you add active leadership and open peer comparisons, you create a climate where progress does not just happen once; it keeps happening [21].

Leadership, IPC systems, and safety culture as enablers of change

Upon examining the broader context, it becomes evident that advancements in postoperative care and reductions in SSI rates are unlikely to endure without continued investment in leadership, processes, and governance. The progress achieved in IPC training, safety culture, and surveillance, contrasted with the little advancement in antibiotic prescribing, conveys a significant message. One cannot only instruct clinicians to improve and anticipate a resultant change. If the surrounding systems lack support, if policies are ambiguous, or if accountability is absent, entrenched behaviors persist. The significance lies in the location of the occurrence. This is Sudan, a region where health systems are precariously maintained. There are labor shortages, unreliable supply chains during critical times, and infrastructure precariously maintained with few resources. Did the leadership and IPC systems indeed strengthen in this context? That is not a trivial matter. It demonstrates that even in the most delicate and fragmented environments, a nationwide audit network such as the Clinical Leadership, Evaluation, and Action Network (CLEAN) can ignite progress and stimulate action. Genuine transformation does not invariably await optimal circumstances.

Strengths and limitations

The national emphasis of this study is one of its advantages. A coherent strategy, a substantial and varied patient cohort, and comprehensive site involvement throughout all audit cycles instill confidence that our findings represent genuine patterns rather than isolated occurrences. Clinical data, environmental assessments, and leadership metrics enabled us to provide a more comprehensive overview of SSI prevention beyond mere technological measures.

However, it is important to note several limitations. The audit did not look at surgical-site infection rates or other patient-level outcomes, but rather compliance with recommended infection-prevention practices. Thus, while improvements in reported practice were observed, the study was unable to quantify any corresponding reduction in infection rates. Data were collected using anonymous questionnaires only and no direct observation, independent documentation of infection events or patient-level clinical data were collected. Also, the hospitals that took part in the study had different baseline resources and capacity, which could have had an impact on the implementation of recommended practices and on the level of improvement achieved.

Because the questionnaire was anonymous and responses were not individually linked across cycles, the study could not control for individual-level test–retest effects or determine whether the same clinicians participated in both cycles. Consequently, changes in reported adherence may partly reflect differences in respondent composition, increased awareness of the audit, or social-desirability effects following the intervention. Although the same hospitals, questionnaire, dissemination routes, and sampling targets were maintained across cycles, the before-and-after comparison should therefore be interpreted as a comparison of aggregate reported adherence rather than a paired assessment of individual-level change. Second, the audit primarily assessed reported adherence to SSI prevention practices and did not prospectively collect patient-level SSI incidence, mortality, antibiotic consumption, antiseptic utilization, or hospital length of stay. Therefore, the observed improvements in process measures cannot be interpreted as evidence of a corresponding reduction in SSI incidence or other patient-level outcomes. Future audit cycles should incorporate objective clinical and resource-use indicators alongside process measures to strengthen outcome assessment and causal inference.

Implications for policy and future research

These findings offer robust empirical evidence for the formulation and execution of context-specific national SSI prevention guidelines in Sudan. Future initiatives must emphasize the preservation of innovations in high-impact practices, the enhancement of antimicrobial stewardship, and the alignment of process improvements with patient outcomes. Future audit cycles must incorporate data on SSI rates and antibiotic utilization to enhance causal inference and facilitate cost-effectiveness analyses. Incorporating SSI surveillance, IPC leadership responsibilities, and involvement in audits under national accreditation and regulatory frameworks might significantly enhance sustainability.

Future iterations of the CLEAN audit should combine process indicators with objective patient- and system-level outcomes. These could include procedure-specific SSI incidence, postoperative mortality, hospital length of stay, antibiotic utilization, and consumption of surgical antiseptics. Where feasible, department-level clinical audits and direct observation could complement self-reported questionnaire data and reduce the potential influence of respondent and test–retest effects. Such longitudinal outcome measures would allow assessment of whether improvements in reported adherence translate into measurable improvements in patient outcomes and resource utilization.

Conclusion

This national multicenter audit demonstrated significant increases in reported adherence to several evidence-based SSI prevention practices following a structured audit–feedback intervention across participating Sudanese hospitals. Improvements were observed across preoperative, intraoperative, postoperative, and IPC-system domains, although the magnitude of change varied between practices. Because the study used anonymous, aggregate before-and-after assessments and did not measure patient-level SSI outcomes, the findings should be interpreted as evidence of improved reported adherence rather than definitive evidence of reduced SSI incidence. The intervention provides a potential foundation for continued quality improvement and surveillance; longer-term, longitudinal audits incorporating objective clinical outcomes, including procedure-specific SSI rates, antibiotic utilization, and hospital length of stay, are needed to assess sustainability and determine the clinical impact of these improvements. To keep this going, keep leaders involved, make audits a regular part of the process, and link the process to outcomes. This is not simply the narrative of Sudan; it is a guide for any place with few resources that wants to do better surgery with less.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Ethical approval

The audit formed part of ongoing national efforts to improve surgical quality and infection prevention. Necessary approvals and administrative clearances were obtained from relevant health authorities and institutional leadership prior to data collection. Findings are presented only in aggregate form (hospital, state and national), with the explicit aim of supporting service improvement rather than appraising individual clinicians. This study complies with the principles laid down in the Declaration of Helsinki.

Consent to participate

Participation by doctors was voluntary; completion and submission of the online questionnaire were taken as implied consent. No patient-identifiable information was collected, and all clinician responses were anonymized before analysis.

Consent for publication

Written informed consent for publication has been obtained from all participants or their legal representatives.

Ethics declaration

Written informed consent to take part in the study has been obtained from all participants or their legal representatives. The privacy rights of participants have been observed.

This study was performed in compliance with relevant laws, regulatory frameworks, and guidelines where the research took place. This study was approved by the Sudan Federal Ministry of Health’s ethical committee. (Approval No. FMH258D340)

Data availability

Data will be available upon request.

Declaration of generative AI and AI-assisted technologies in the writing process

The authors used Nano Banana Pro (an AI-assisted image generation tool) solely for the creation of the graphical abstract associated with this manuscript. The tool was employed to translate the study’s concepts into a visual format based on detailed prompts provided by the authors. All scientific content, study design, results, and interpretations were entirely developed and verified by the authors.

The authors maintained full oversight throughout the process, including prompt design, iterative refinement, and critical review of the generated output to ensure accuracy, originality, and compliance with journal guidelines. No AI tool was used in the writing, analysis, or interpretation of the manuscript text. The final graphical abstract was carefully reviewed and approved by all authors.

CRediT authorship contribution statement

Yousif Omer Elgaili Yousif: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Resources, Project administration, Methodology, Investigation, Data curation, Conceptualization. Baha Aldeen Alshareif: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Project administration, Methodology, Investigation, Data curation, Conceptualization. Ahmed Abdellateef Hassan Bakry: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Project administration, Methodology, Investigation, Data curation, Conceptualization. Mohamedelmustafa Yahya Mohamed Eldouma: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Ola Adil Dafaallah: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Project administration, Methodology, Investigation, Data curation, Conceptualization. Nizar I.M. Yaqoub: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Project administration, Methodology, Investigation, Data curation, Conceptualization. Abdulrahman Mohammed Abdulrahman Abouh: Writing – review & editing, Writing – original draft, Visualization, Validation, Methodology, Investigation, Conceptualization. Nidal Ahmed Abdalgader Abdalhadi: Writing – review & editing, Writing – original draft, Visualization, Validation, Methodology, Investigation, Conceptualization. Hozifa Hussein Abdelgayoum Mohamed: Writing – review & editing, Writing – original draft, Visualization, Validation, Methodology, Investigation, Conceptualization. Shahd Jaffer Mohammed Khire: Writing – review & editing, Writing – original draft, Visualization, Validation, Methodology, Investigation, Conceptualization. Ola Sharafeldin Mohamed Elhassan Hussein: Writing – review & editing, Writing – original draft, Visualization, Validation, Methodology, Investigation, Conceptualization. Rayan Khalifa Eltayeb: Writing – review & editing, Writing – original draft, Visualization, Validation, Methodology, Investigation, Conceptualization. Jumaa Mohammed Abdallah Hamed: Writing – review & editing, Writing – original draft, Visualization, Validation, Methodology, Investigation, Conceptualization. Solima Mohammed Abdelgadir Mohammed: Writing – review & editing, Writing – original draft, Visualization, Validation, Methodology, Investigation, Conceptualization. Abdulrahman Mohammed: Writing – review & editing, Writing – original draft, Visualization, Validation, Methodology, Investigation, Conceptualization. Abubakr Alsideeg Alfadhl Aljaily Alfadhl: Writing – review & editing, Writing – original draft, Visualization, Validation, Methodology, Investigation, Conceptualization. Abobakar Mohammed Abdelrahman Dafaalla: Writing – review & editing, Writing – original draft, Visualization, Validation, Methodology, Investigation, Conceptualization. Mohab Abdallhameed Hassan Elmubarak: Writing – review & editing, Writing – original draft, Visualization, Validation, Methodology, Investigation, Conceptualization. Mohamed Maisara Ali Hussein Qurashi: Writing – review & editing, Writing – original draft, Visualization, Validation, Methodology, Investigation, Conceptualization. Aisha Abdalla Ali Dafalla: Writing – review & editing, Writing – original draft, Visualization, Validation, Methodology, Investigation, Conceptualization. Mohannad Osman Abdallah Sulieman: Writing – review & editing, Writing – original draft, Visualization, Validation, Methodology, Investigation, Conceptualization. Afraa Nsreldeen Bala Awadelkareem: Writing – review & editing, Writing – original draft, Visualization, Validation, Methodology, Investigation, Conceptualization. Eltayeb Dirar Alsiddig Ali: Writing – review & editing, Writing – original draft, Visualization, Validation, Methodology, Investigation, Conceptualization. Musa Eltayeb Musa Adam: Writing – review & editing, Writing – original draft, Visualization, Validation, Methodology, Investigation, Conceptualization. Mustafa Aboalgasim Abozaid Mohamed: Writing – review & editing, Writing – original draft, Visualization, Validation, Methodology, Investigation, Conceptualization. Ahmed Muaz Ahmed Medani: Writing – review & editing, Writing – original draft, Visualization, Validation, Methodology, Investigation, Conceptualization. Osman Taleballah: Writing – review & editing, Writing – original draft, Visualization, Validation, Methodology, Investigation, Conceptualization. Raghad Omar Abdalla: Writing – review & editing, Writing – original draft, Visualization, Validation, Methodology, Investigation, Conceptualization. Mahmoud Qasmelsid: Writing – review & editing, Writing – original draft, Visualization, Validation, Methodology, Investigation, Conceptualization. Ragda Abdallah: Writing – review & editing, Writing – original draft, Visualization, Validation, Methodology, Investigation, Conceptualization. Mahil Abdalla: Writing – review & editing, Writing – original draft, Visualization, Validation, Methodology, Investigation, Conceptualization. Osama Suliman Idris Mahmoud: Writing – review & editing, Writing – original draft, Visualization, Validation, Methodology, Investigation, Conceptualization.

Declaration of competing interest

The authors have no competing interests to declare.