Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

GlobalSurg Collaborative

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Abstract

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p<0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p<0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication. Funding: DFID-MRC-Wellcome Trust Joint Global Health Trial Development Grant, National Institute of Health Research Global Health Research Unit Grant.

Original languageEnglish
Pages (from-to)516-525
Number of pages10
JournalThe Lancet Infectious Diseases
Volume18
Issue number5
DOIs
Publication statusPublished - 1 May 2018

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Surgical Wound Infection
Human Development
Multicenter Studies
Cohort Studies
Risk Adjustment
Incidence
Logistic Models
Pragmatic Clinical Trials
Research
Health Priorities
United Nations
Health Facilities
National Institutes of Health (U.S.)
Centers for Disease Control and Prevention (U.S.)

ASJC Scopus subject areas

  • Infectious Diseases

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@article{3204001801b14baf88fb4dcb6e437171,
title = "Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study",
abstract = "Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5{\%}) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2{\%}) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2{\%}) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3{\%}) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4{\%}] of 7339 patients), middle (549 [14·0{\%}] of 3918 patients), and low (298 [23·2{\%}] of 1282) HDI (p<0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8{\%}] of 574 patients in high-HDI countries; 74 [31·4{\%}] of 236 patients in middle-HDI countries; 72 [39·8{\%}] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95{\%} credible interval 1·05–2·37; p=0·030). 132 (21·6{\%}) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6{\%}) of 295 patients in high-HDI countries, in 37 (19·8{\%}) of 187 patients in middle-HDI countries, and in 46 (35·9{\%}) of 128 patients in low-HDI countries (p<0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication. Funding: DFID-MRC-Wellcome Trust Joint Global Health Trial Development Grant, National Institute of Health Research Global Health Research Unit Grant.",
author = "{GlobalSurg Collaborative} and Aneel Bhangu and Ademuyiwa, {Adesoji O.} and Aguilera, {Maria Lorena} and Philip Alexander and Al-Saqqa, {Sara W.} and Giuliano Borda-Luque and Ainhoa Costas-Chavarri and Drake, {Thomas M.} and Faustin Ntirenganya and Fitzgerald, {J. Edward} and Fergusson, {Stuart J.} and James Glasbey and Ingabire, {JC Allen} and Lawani Isma{\"i}l and Salem, {Hosni Khairy} and Kojo, {Anyomih Theophilus Teddy} and Lapitan, {Marie Carmela} and Richard Lilford and Mihaljevic, {Andre L.} and Dion Morton and Mutabazi, {Alphonse Zeta} and Dmitri Nepogodiev and Adisa, {Adewale O.} and Riinu Ots and Francesco Pata and Thomas Pinkney and Tomas Poškus and Qureshi, {Ahmad Uzair} and {Ramos-De la Medina}, Antonio and Sarah Rayne and Shaw, {Catherine A.} and Sebastian Shu and Richard Spence and Neil Smart and Stephen Tabiri and Harrison, {Ewen M.} and Chetan Khatri and Midhun Mohan and Zahra Jaffry and Afnan Altamini and Andrew Kirby and Kjetil S{\o}reide and Gustavo Recinos and Jen Cornick and Modolo, {Maria Marta} and Dushyant Iyer and Sebastian King and Tom Arthur and Nahar, {Sayeda Nazmum} and {Nik Mahmood}, {Nik Ritza Kosai}",
year = "2018",
month = "5",
day = "1",
doi = "10.1016/S1473-3099(18)30101-4",
language = "English",
volume = "18",
pages = "516--525",
journal = "The Lancet Infectious Diseases",
issn = "1473-3099",
publisher = "Lancet Publishing Group",
number = "5",

}

TY - JOUR

T1 - Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries

T2 - a prospective, international, multicentre cohort study

AU - GlobalSurg Collaborative

AU - Bhangu, Aneel

AU - Ademuyiwa, Adesoji O.

AU - Aguilera, Maria Lorena

AU - Alexander, Philip

AU - Al-Saqqa, Sara W.

AU - Borda-Luque, Giuliano

AU - Costas-Chavarri, Ainhoa

AU - Drake, Thomas M.

AU - Ntirenganya, Faustin

AU - Fitzgerald, J. Edward

AU - Fergusson, Stuart J.

AU - Glasbey, James

AU - Ingabire, JC Allen

AU - Ismaïl, Lawani

AU - Salem, Hosni Khairy

AU - Kojo, Anyomih Theophilus Teddy

AU - Lapitan, Marie Carmela

AU - Lilford, Richard

AU - Mihaljevic, Andre L.

AU - Morton, Dion

AU - Mutabazi, Alphonse Zeta

AU - Nepogodiev, Dmitri

AU - Adisa, Adewale O.

AU - Ots, Riinu

AU - Pata, Francesco

AU - Pinkney, Thomas

AU - Poškus, Tomas

AU - Qureshi, Ahmad Uzair

AU - Ramos-De la Medina, Antonio

AU - Rayne, Sarah

AU - Shaw, Catherine A.

AU - Shu, Sebastian

AU - Spence, Richard

AU - Smart, Neil

AU - Tabiri, Stephen

AU - Harrison, Ewen M.

AU - Khatri, Chetan

AU - Mohan, Midhun

AU - Jaffry, Zahra

AU - Altamini, Afnan

AU - Kirby, Andrew

AU - Søreide, Kjetil

AU - Recinos, Gustavo

AU - Cornick, Jen

AU - Modolo, Maria Marta

AU - Iyer, Dushyant

AU - King, Sebastian

AU - Arthur, Tom

AU - Nahar, Sayeda Nazmum

AU - Nik Mahmood, Nik Ritza Kosai

PY - 2018/5/1

Y1 - 2018/5/1

N2 - Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p<0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p<0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication. Funding: DFID-MRC-Wellcome Trust Joint Global Health Trial Development Grant, National Institute of Health Research Global Health Research Unit Grant.

AB - Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p<0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p<0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication. Funding: DFID-MRC-Wellcome Trust Joint Global Health Trial Development Grant, National Institute of Health Research Global Health Research Unit Grant.

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U2 - 10.1016/S1473-3099(18)30101-4

DO - 10.1016/S1473-3099(18)30101-4

M3 - Article

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AN - SCOPUS:85041918898

VL - 18

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EP - 525

JO - The Lancet Infectious Diseases

JF - The Lancet Infectious Diseases

SN - 1473-3099

IS - 5

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