Surgical site infection rates in 6 cities of India

Surgical site infections are a threat to patient safety. However, in India, data on their rates stratified
by surgical procedure are not available.

From January 2005 to December 2011, the International Nosocomial Infection Control Consortium
(INICC) conducted a cohort prospective surveillance study on surgical site infections in 10 hospitals in 6 Indian cities. CDC National Healthcare Safety Network (CDC-NHSN) methods were applied and surgical procedures were classified into 11 types, according to the ninth edition of the International Classification of Diseases.

1189 surgical site infections were documented, associated with 28 340 surgical procedures (4.2%; 95%
CI 4.0–4.4). Surgical site infections rates were compared with INICC and CDC-NHSN reports, respectively: 4.3% for coronary bypass with chest and donor incision (4.5% vs 2.9%); 8.3% for breast surgery (1.7% vs 2.3%); 6.5% for cardiac surgery (5.6% vs 1.3%); 6.0% for exploratory abdominal surgery (4.1% vs 2.0%), among others.

In most types of surgical procedures, surgical site infections rates were higher than those reported
by the CDC-NHSN, but similar to INICC. This study is an important advancement towards the knowledge of surgical site infections epidemiology in the participating Indian hospitals that will allow us to introduce targeted interventions.

It is difficult to ignore the burden posed by surgical site infections (SSIs) on patients’ safety in terms of pain, suffering, delayed wound healing, increased use of antibiotics and antibiotic resistance, revision surgery, increased length of hospital stay, mortality, morbidity and excess healthcare costs. SSIs have also been associated with the emergence multi-drug resistant bacteria. However, the incidence of SSIs in India has not been systematically studied. Therefore, there are neither global SSI rates nor SSI rates stratified by surgical procedure (SP) according to the to the ninth edition of the International Classification of Diseases criteria that enables a basis for international bench-marking.

According to the World Bank’s categorization based on the 2012 gross national per capita income, 68% of the world countries are low-income and lower middle-income economies, which can also be referred to as lower-income countries, or developing countries.6 However, the incidence of SSIs in limited-resource countries has not been systematically assessed in these settings.

Surveillance programs focused on healthcare-associated infections (HAI), including surgical site infections (SSIs), are essential tools to prevent their incidence and reduce their adverse effects, thereby allowing for the reduction of patients’ risk of infection. As widely shown in the literature from high-income countries, including the United States, the implementation of an effective surveillance approach can lead to a reduction in the incidence of HAI by as much as 30%, and by 55% in the case of SSIs. Within the scope of developing countries, several reports from the International Nosocomial Infection Control Consortium (INICC) have also shown that if surveillance and infection control strategies are applied in limited-resource countries, HAIs can also be reduced significantly.

This study was designed to determine the incidence of SSIs in 6 cities in 10 hospitals of India, a limited-resource economy. In our study, SSI rates in breast surgery and cardiac surgery were higher than both the INICC 2005–2010 and CDC-NHSN for 2006–2008 reported rates. In the cases of coronary bypass with chest and donor incision, hip prosthesis, knee prosthesis and exploratory abdominal SPs, SSI rates were higher than CDC-NHSN’s reported rates, but similar to INICC rates. SSI rates for craniotomy and thoracic surgery were lower than INICC, but higher than CDC-NHSN’s rates. SSI rates for limb amputation and vaginal hysterectomy procedures were similar to both INICC and CDC-NHSN’s reported rates. Finally, SSI rate for herniorrhaphy was higher than the INCC’s rate, but similar to the CDC-NHSN’s rate.

During the last few decades, the CDC has been the only available source to provide a basis for comparison of hospital infection rates worldwide. Comparing the CDC’s hospitals’ rates with those of hospitals fromWestern Europe and Oceania is considered valid, due to their similar socio-economic conditions. In contrast, the comparison of CDC’s hospitals’ rates and those of hospitals with limited-resources or with sufficient available resources, but without enough experience in the field of infection control, should involve the consideration of the mentioned disadvantages in terms of socio-economic factors. US hospitals enjoy more than a 50-year unrivaled experience in infection control and surveillance, sufficient human and medical supply resources availability, and a comprehensive legal framework backing infection control programs, including mandatory surveillance and hospital accreditation policies. The higher SSI rates found in our study, in comparison to the rates for CDC’s hospitals, have also been influenced by such factual background. The relation between the HAI rates
and the type of hospital (public, academic and private), and the relation between HAI rates and the country’s socio-economic level (defined as low-income, mid-low-income and high- income) have recently been analyzed and published by the INICC. Such studies’ findings showed that a higher country socio-economic level was correlated with a lower infection risk.

Conclusions
The comparison between this study’s findings and the data reported by the INICC 2005–2010 showed that SSI rates were similar in 55% of the analyzed SPs, whereas if compared with the CDC-NHSN for 2006–2008, SSI rates in this study were significantly higher in 73% of the analyzed SPs. This paper represents an important advance towards the knowledge of SSI epidemiology in India that will allow us to introduce targeted interventions. Furthermore, this study shows that INICC is a valuable international bench-marking tool, in addition to the CDC-NSHN, whose participating hospitals have unrivaled infection control experience and resources.

 

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