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Low-income countries predisposed to higher surgical site infection risk after GI surgery

Roshini Claire Anthony
06 Mar 2018

Surgical site infections (SSIs) following gastrointestinal surgery occur more frequently in countries deemed low-income by the United Nation’s Human Development Index (UN HDI) compared with middle- or high-income countries, a recent study found.

“Our study shows that low income countries carry a disproportionately high burden of infections linked to surgery,” said study lead investigator Dr Ewen Harrison from the University of Edinburgh, Scotland, UK.

The study cohort comprised 12,539 patients from 343 centres in 66 countries (mean age 43.5 years, 51.5 percent female), of whom 58.5, 31.2, and 10.2 percent were from high-, middle-, and low-HDI countries, respectively, as per the UN HDI. Within 30 days of surgery, 1,538 patients (12.3 percent) developed surgical site infections.

The incidence of SSIs at 30 days was highest in low-income countries (23.2 percent) compared with middle-income (14.0 percent) or high-income countries (9.4 percent; p<0.001), with patients in low-HDI countries having a 60 percent increased risk for SSIs compared with their middle- and high-HDI counterparts (adjusted odds ratio [adjOR], 1.60, 95 percent credible interval, 1.05–2.37; p=0.030). [Lancet Infect Dis 2018;doi:10.1016/S1473-3099(18)30101-4]

Conversely, middle-HDI countries did not have an elevated risk for SSIs compared with high-HDI countries (adjOR, 1.12; p=0.539).

Patients who developed an SSI also had a longer length of hospitalization than those who did not develop an infection (median 7.0 vs 2.0 days; p<0.001).

SSIs were more common following dirty* procedures, regardless of HDI level (39.8, 31.4, and 17.8 percent in low-, middle-, and high-HDI countries, respectively).

“[B]ecause there was no significant interaction between contamination and HDI, [this suggests] that HDI is an independent risk factor for SSI, irrespective of intraoperative contamination,” said the researchers.

 

The potential link between SSIs and antimicrobial resistance

Patients in low-HDI countries were more likely to receive preoperative or prophylactic antibiotics or both (95.5 percent) compared with patients in middle-HDI (86.6 percent) or high-HDI countries (87.8 percent; p<0.001), and were also more likely to use postoperative antibiotics (adjOR, 4.37; p=0.002).

Antibiotic-resistant infections were most commonly detected among patients in low-HDI countries (35.9 percent), followed by middle- (19.8 percent) and high-HDI countries (16.6 percent; p<0.001).

“These findings begin to characterize the relationship between SSIs and global antimicrobial resistance,” said Harrison.

“Worldwide, large amounts of antibiotics were consumed to prevent and treat SSIs, yet in a fifth of cases the causative microorganism was resistant to the pre-surgery antibiotics given, and this increased to one of three cases in low-income countries. This high prevalence illustrates a potentially important area for improvement worldwide, and reducing SSIs will help to ensure safe and essential surgery around the world,” he said, recommending further study into the SSI-antibiotic resistance link.

“[T]he relative overuse of antibiotics in low-income and middle-income countries, particularly in the postoperative period, is associated with increased antimicrobial resistance. If this is truly the most important contributor to the SSI problem, an enhanced effort in antimicrobial stewardship will also need to be implemented,” said Professor Robert G Sawyer from the Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, and Associate Professor Heather L Evans from the University of Washington, Seattle, Washington, US, in an editorial. [Lancet Infect Dis 2018;doi:10.1016/S1473-3099(18)30118-X]

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