Incidence of Surgical Site Infections and Surgical Antimicrobial Prophylaxis in JNMC, Bhagalpur, India

Abstract

Background:

Surgery site infections (SSIs) are infections that arise in surgery for an operative wound infection surveillance within 30 days of surgery or 90 days after implant installation. JNMC, Bhagalpur, India, intended to look at the pre- and postoperative use of antibiotics.

Methods:

Four hundred twelve patient charts were analyzed for four months in JNMC, Bhagalpur, India as part of a hospital-based cross-section study. The study covered all patients 13 years of age and older who had been admitted to the hospital and had undergone various surgeries. In addition, a P value was preserved for the further multivariate analysis, using multiple logistic regressions, to study the association between the resulting variable and the predictor.

Results:

The general surgery operation included 152 of the 412 patients, while the remainder was for different operations. A single operative antibiotic was administered to the majority of patients, followed by two surgical prophylactic medications. Before the hospital was discharged, 40 of the patients experienced surgical site infections. In almost half of these cases, ceftriaxone and metronidazole were combined with SSIs. Emergency surgery patients were 2.6 times more likely to have a SSI than optional surgery patients. The SSIs were 2.5 times more likely in patients who were not given antibiotic prophylaxis. In our investigation, the protection against SSI was found to include clean-contaminated and contaminated wound types.

Conclusions:

According to this study, the majority of patients received antimicrobial prophylaxis. In the hospital where the study was done, the total incidence of SSIs was 11.1%. The most frequently given antibiotic was ceftriaxone. The absence of prevention, wound type, and types of surgery has all been associated with SSI development.

INTRODUCTION

Disease Control and Prevention Centers define OSIs as infections that arise in a period of 30 days following operation or monitoring of surgical infection carried out within 90 days of surgery when an implant has been placed. Implants must be controlled. It is divided into three levels (superficial incisional, deep incisional, and organ or space infection).[1] In low- and middle-income countries (LMICs), it is the most common kind of infection related to health care (HAI). About 1 in 10 individuals in LMICs who undergo surgery acquire a surgical site infection (SSI).[2] The most prevalent HAI in surgical patients is postoperative infections.[3,4,5,6,7] SSIs account for 14%–16% of all patients undergoing hospitalizations and 38% of all surgical patients, the second most prevalent infections connected with hospitals.[8,9,10] It is twice or three times higher in developing countries, particularly Sub-Saharan Africa, than in affluent countries.[11] The second most frequent HAI in Europe and USA is surgical site infection. In Europe, SSI has a population of over 500,000 per year at the cost of USD 19 million; in the United States, SSI provides more than USD 10 billion a year for the patient to spend over 400,000 more days in the hospital.[12,13]

Despite progress in surgical methods and understanding of pathophysiology of surgical infections, SSIs remain a severe challenge for operative civilization.[14,15] Therefore, antibiotic prophylaxis, which is regarded as crucial for bacterial development to control and dramatically reduce the occurrence of SSIs, should be initiated before contamination. 60% of SSIs are expected to be preventable, largely connected to the implementation of suggested evidence-based methods such as preoperative antibiotic scheduling, selection and duration.[10]

For the prevention of postoperative infection or the treatment of established infections, antibiotics in surgical care centers are required.[15] Nearly 30%–50% of hospital-based antimicrobials are for surgical prophylaxis, and 30%–90% of them are inadequate.[9] Moreover, they are often employed for a long time and with excessive range coverage in the wrong timing.[13] Cephalosporin antibiotics (e.g., cefazoline) are first-line medicines for most of the operations aimed against most organisms, while at the same time preventing wide-spectrum antimicrobial prophylaxis which may contribute to antifungal resistance development. The length of the operation is not to exceed 24 hours of antimicrobial prophylaxis (SAP).[11] The effectiveness of prophylaxis is determined by properly selecting antibiotics, time of starting administration, quantity of dosage given during surgery, and usage of post-surgical medicines. Failure to properly perform any of this may affect the rate of SSI.[14,15,16]

This study aimed at assessing the patterns of SAP and the rate of SSIs in surgically operated patients because of information gap in the suitability of the SAP system in the hospital.

MATERIALS AND METHODS

This study was conducted in Jawaharlal Nehru Medical College (JNMC), Bhagalpur, India. An intersectional hospital study was conducted using a simple random test, which includes a four-month (10 June to 10 September 2021) review of patient chart data in JNMC, Bhagalpur, India. Patients were admitted. All the patients admitted to surgery at operating centers and operating during the study period were the source and study population of all patients who were responsible for general, orthopedic, gynecology and obstetrics, urology and neurologic operations. The study excluded those who were under 13 years of age and who operated in another hospital and afterwards reported to the JNMC, Bhagalpur, Indi

A single population proportion of formula 30 with a P value of 0.5 and a marginal error of 5% and a confidence interval (CI) of 95% (Z = 1.96) were used to estimate the sample size. Therefore, 400 persons were calculated for the sample size. The sample size was 420 considering 10% of incomplete patient records. Finally, every surgical ward took the required proportion of the sample. We also enrolled 412 analytical research participants as 8 patients failed to meet the criteria for participation.

Information was gathered through the use of a structured data collection tool, which included the following information: the patient's age and gender, surgery performed, development of SSIs, classification of SSIs, surgical ward in which the patient was admitted, antimicrobial agent prescribed for prophylactic and postoperative treatment, route and time of antimicrobial administration, intraoperative redosing, and the basis of antimicrobial prescription for postoperative treatment.

RESULTS

Sociodemographic and clinical characteristics

Four hundred twelve people were enrolled in this trial. Two hundred thirty (55.9%) of all types of operations performed for male patients were conducted. The age of the study participants spanned between 14 and 80 years with an average age of 35.1 (SD = 12.1) years and a mean age range of 35.1 (range = 19.6–55.4) years. A total of 150 patients were admitted for general operation while others were admitted for different types of operations.

Antibiotics utilization practice in surgery

Most participants in the study received preventive antibiotics limited received therapeutic antibiotics. In this study, 170 patients (79.7%) were mostly treated with a single prophylactic antibiotic and were followed by two medicines (50; 20.3%) for the same purpose. Injection-based ceftriaxone and metronidazole were prescribed to the study participants who received antibiotic therapy, about half of whom were injected. Parenteral (IV) route was the preferred route to administer: 240 and 72 respectively, for prevention and therapeutic purposes.

In terms of timed preoperative prophylaxis, half of the patients were treated with antibiotics 30 minutes before surgery and ~48 hours postoperative prophylaxis [Table 1], which is the improper period, was obtained by the same number of study participants. 91.1% of the study participants received an appropriate dose of surgical antibacterial prophylaxis.

Table 1.

Timing, duration, and appropriateness of surgical anti-microbial prophylaxis

Practice of Surgical Antimicrobial Prophylaxis	Number
Timing of SAP
30 minutes before surgery	124
At the time of anesthesia	64
30 minutes to 1 hour before incision	34
1 to 2hours before incision	2
Indication of SAP
Indicated and administered	224 (91.1%)
Not indicated but administered	22 (8.9%)

Incidence of SSIs

SSIs were seen in 46 patients (11.1%) prior to hospital discharge, out of 413 patients who had been operated on various surgery indications.

Seven factors (age, sex, concomitant disease, and the antimicrobial prophylactic status, types of operation, longevity and wound type) had a P value of ~0.2 and became candidates for multiple logistical regressions. The number of emergencies in SSIs that developed was 2.6 times higher than in the case of elective surgery (AOR = 2.647; 95% IC = 1.4060–4.983). Patients who were without antibiotic prophylaxis were 2.6 times more likely to have SSI than those who had preoperative, pre-pathotic prophylaxis (AOR = 2,572; 95% CI = 102 to 6,485; Table 2).

Table 2.

Factors associated with SSIs

Variables	SSI (N, %)	No SSI (N, %)	AOR (95%CI)	P
Age in years
⩽20	2	10	1
20–39	20	222	0.22	0.06
40–59	12	89	1.02	0.90
⩾60	11	47	0.67	0.70
Sex
Male	330	192	0.5	0.04
Female	16	175	1
Presence of comorbid illness
Yes	8	108	0.46	0.09
No	38	259	1
Prophylactic antibiotics
Received	38	202	1
Not received	8	165	2.5	0.04
Duration of surgery
<1	16	155	1
1-2	20	138	1.2	0.57
>2-3	7	45	0.9	0.9
>3-4	3	22	1.8	0.3
>4	1	6		0.98
Types of surgery
Elective	27	254	1
Emergency	19	113	2.6	0.00
Wound class
Clean	3	92	1
Clean contaminated	15	157	0.11	0.00
Contaminated	12	51	0.29	0.00
Dirty	16	67	0.6	0.40

In this study, the patients who were not given SAP had emergency operations and were substantially related with the onset of SSIs with clean-contaminated and contamination types.

DISCUSSION

This study employed preoperative, postoperative antibiotics, and examined the incidence of SSIs in JNMC, Bhagalpur, India. Sociodemographic and clinical features, antibiotic use in surgery, SAP and treatment practice, and SSI-associated variables were investigated.[5]

Five hundred twenty-four patients were operated throughout the study period, out of which 412 were enrolled. Antibiotics were prescribed for SAP and/or therapy out of 340 individuals. Forty patients had SSIs. The incidents of SSI in India (3.38%) and Brazil were greater than the surveys conducted (3.4 percent).[15] This may be because most types of surgeries and the total difference in sample size in our study were included. However, two Ethiopian studies (20.6% and 32% and 19.1%) and a Ugandan study observed a greater incidence rate (16.4%).[16]

The foundation for antibiotic prescription was empirical in all patients, including both prophylaxis and therapy. This was identical to a study carried out in Namibia.[8] Ceftriaxone, which was the most widely used antibiotic for both indications, in combination with other antibiotics in this study, was the best prescribed antibiotic. This may be because the relevant SAP agent, like cefazolin, is not available.[7] The results of this investigation matched with the US study.[3] One hundred twenty out of 246 patients received a prophylactic antibiotic 30 minutes before surgery. This finding is corroborated by a study on the viability of preventive antibiotics in stomach cancer.[8] According to recommendations by the American Academy of Family Physicians,[9] the use of prophylactic antibiotics should be started one hour before the procedure, and the superstructure in which our study found that SAP was received by most of the study patients. According to various studies,[10] the antimicrobial prophylaxis should be below 24 hours for a majority of procedures according to the American Society of Health-System Pharmacists' (ASHP) Therapeutic Guidelines.

CONCLUSION AND RECOMMENDATIONS

This study revealed that SAP antibiotics were administered to majority of the patients. In the study, the total incidence rate of SSI was 11.1%. Ceftriaxone was the medication used most frequently. The development of SSI was largely connected with the lack of SAP, wound class, and surgical kinds. The majority of the recommended SAP antibiotics, especially cefazoline, need to be used in this trial. Continuous supervision of the SAP practice and of ongoing training programs for all surgical centers may also be important. We also urge a hospital infection monitoring system, and a wound monitoring program must be implemented to minimize the infection rate of surgical wounds to an acceptable level.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.