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Surgical Site Infection Complicating Digestive Surgery in Developing Countries

Souleymane OUEDRAOGO*, Jean Luc KAMBIRE, Salam OUEDRAOGO, Edgar OUANGRE, Ismaël DIALLO, Maurice ZIDA, Emile BANDRE

Department of Surgery, University Ouaga 1 Pr Joseph Ki Zerbo, Ouagadougou, Burkina Faso

Abstract: Surgical site infections are frequent and responsible for significant morbidity in patients who undergo digestive surgery. However, very little is known about the aspects of surgical site infections in sub-Saharan Africa. The purpose of this study was to assess the prevalence and identify risk factors of surgical site infections in patients who were treated in the Digestive Surgery Department of Tenkodogo Regional Hospital in Burkina Faso. From 1 January to 31 December 2016 we performed a descriptive study in the Department of Digestive Surgery of Tenkodogo Regional Hospital in Burkina Faso. All patients who underwent digestive tract surgery during this period were followed. Those patients whose post-operative surgical sites were complicated by infection were included in this study. Surgical site infection was diagnosed according to the CDC definition. Bacteriological sampling was performed in all included patients. In all, 964 patients underwent surgery during the study period. One-hundred--fourteen patients presented with surgical site infection, the rate of which was 11.8%. The mean age of the included patients was 48.7 years. Seventy-two patients were women (63.2%) and 42 were men. The risk of surgical site infection was significantly higher in women than in men (74.2% vs 25.8%, p <0.001). The risk was also higher in patients living below the poverty line (71% vs 29%, p <0.001). Clinically, the risk of surgical site infection was higher in emergency surgery than in scheduled surgery (16.7% vs 4.6%, p<0.001). Contaminated surgery, or dirty surgery, was significantly more risky than clean surgery (p<0.001). With respect to bacteria, the most commonly isolated microbes were E. coli (66.7%) and S. aureus (15%). Treatment mainly consisted of appropriate antibiotic therapy and local care. Three deaths were recorded for a mortality rate of 2.6%. Surgical site infections are frequent in sub-Saharan environments. The risk factors for surgical site infection are related to poverty.

Keywords: surgical site infection, digestive surgery, bacteriology, risk factor, Burkina Faso

Citation: Souleymane OUEDRAOGO, Jean Luc KAMBIRE, Salam OUEDRAOGO, Edgar OUANGRE, Ismaël DIALLO, Maurice ZIDA, Emile BANDRE, Surgical Site Infection Complicating Digestive Surgery in Developing Countries. Global Journal of Surgery, 6 (1). 6-10. January 2018. doi:10.12691/js-6-1-2

1. Introduction

Surgical site infection is currently defined as an infection that occurs within 30 days after surgery and that affects the skin, subcutaneous tissues, organs or spaces manipulated during surgery [1]. Surgical site infection (SSI) is the most common type of nosocomial infection [2,3]. SSI is responsible for a considerable increase in hospital morbidity, the length of hospital stays and even mortality [3,4]. Moreover, the additional cost of managing patients with surgical site infections is substantial and is approximately US $ 3422 per patient [5]. In industrialized countries, several strategies have been developed for the prevention of SSI [6,7,]. In developing countries, the precariousness of health facilities resources compounds the problem. A 2011 report by the World Health Organization mentioned that the risk of SSI was significantly higher in the sub-Saharan environment [8]. However, few studies have been devoted to SSI in the sub-Saharan environment. Only 24 studies have been identified in the last 20 years by Alexander [9]. We present a prospective study that was performed in the Department of Digestive Surgery at a hospital in sub-Saharan Africa to assess the prevalence and to identify the risk factors for surgical site infections in this environment.

2. Materials and Methods

The aim of this study was to determine the frequency, the risk factors and the bacteriological profile of surgical site infections in the Department of Digestive Surgery at Tenkodogo Regional Hospital in Burkina Faso. We performed a descriptive study that covers the period from January 1, 2016 to December 31, 2016. In this service, the anaesthetic protocol included ceftriaxone at induction. Polyvidone iodine was used in the skin preparation procedure. A preoperative shower was given only to patients who underwent scheduled surgery. Depilation was performed on the inguinal and abdominal incision sites. All the patients who underwent surgery of the digestive tract during this period were followed. Patients who underwent surgery and whose follow-up was complicated by SSI were identified and included in this study. The initial surgeries were classified according to Altemeier's classification.

Surgical site infection was diagnosed as outlined in the CDC definition of nosocomial surgical site infections (1992). A bacteriological study was performed for all included patients. The sampling technique for the bacteriological study depended on the type of surgical site infection. In the case of intra-abdominal suppuration, the collection of pus was performed for each operation using a sterile syringe. In the case of superficial suppuration of the wound, the pus was collected directly in a sterile syringe. In the absence of free pus, a wound swab was performed with a sterile swab provided by the laboratory.

The pus was packaged aseptically and sent to the laboratory within a maximum of 10 minutes. The samples were Gram-stained and examined for microorganisms after culture of the samples on aerobic and anaerobic blood agar, as well as in cooked, aerobic and anaerobic broth. The antibiogram was performed on agar medium. If cultures were negative after 3 days, they were maintained for up to 8 days. The 2011 recommendations of the Antibiogram Committee of the French Microbiology Society (CASFM) were used to interpret the results of the antibiogram. For each included patient, epidemiological, clinical, and bacteriological characteristics were collected using a pre-established survey form. Data analysis was performed on a microcomputer. The Chi square test was used for the comparison of the data with a significance level of p = 0.001.

3. Results

3.1. Epidemiological aspects

During the study period, 964 surgical procedures were performed. In all, 114 patients with surgical site infections were identified and included. The rate of surgical site infections was 11.8%. The age of the patients ranged from 3 to 68 years, with an average age of 48.7 years. Female predominance was noted in 72 cases (63.2%). The most represented socio-professional categories were housewives (n = 54 or 47.4%), farmers (n = 27 or 23.6%) and students (n = 24 or 21%). The majority of patients were of low socioeconomic status and lived in rural areas. Figure 1 illustrates the demographic characteristics of the patients.

The socio-demographic risk factors associated with the occurrence of surgical site infection were gender, geographic origin and socio-economic status. Thus, female patients were at higher risk than male patients (74.2% vs 25.8%, p <0.001). Patients from rural areas had a significantly higher risk than those from urban areas (78.9% vs 21.1%, p <0.001). The risk was higher in patients with low socio-economic status compared with those with a high socio-economic status (71% vs 29%, p <0.001).

Figure 1. Demographic characteristics of the patients ( No surgical site infection, Surgical site infection)

3.2. Clinical Aspects

Surgical site infection was limited to the operative wound in 90 cases (78.9%). In 24 cases (21.1%), SSI occurred in the intra-abdominal suppuration. We noted 96 surgical site infections after emergency surgery (84.2%) versus 18 after scheduled surgery. Table 1 illustrates the distribution of patients according to the type of surgery performed.

Table 1. distribution of patients according to the type of surgery performed

We found a higher risk in emergency surgery than in scheduled surgery (16.7% vs 4.6%, p <0.001). The risk was also significantly lower in the “clean surgery” group. Table 2 illustrates the distribution of patients according to the type of initial surgery performed.

3.3. Bacteriological Aspects

The culture resulted in a single microbe in 60 cases (52.6%), whereas the cultures were negative in 54 cases (47.4%). The most commonly isolated microbe was Escherichia coli, which was found in 40 cases (66.7%). For all species, a predominance of non-Multi Drug-Resistant (non MDR) strains was observed. Table I shows the distribution of bacteria isolated during the culture. Table 2: distribution of bacteria isolated during the culture.

Table 2. Bacteria isolated from culture

Isolated bacteria were sensitive to gentamicin in 28 cases (46.7%), ciprofloxacin in 21 cases (35%) and chloramphenicol in 9 cases (15%). Resistance was frequently noted with ceftriaxone, which is an antibiotic used for anaesthetic induction.

3.4. Therapeutic Aspects

Treatment was based on the type of infection. In the case of suppuration of the operative wound, a partial release of the cutaneous suture allowed an adequate dressing with evacuation of the serositis or the pus. The initial antibiotic therapy was readjusted after the antibiogram was obtained. The dressing was then changed daily until wound healing, as judged by the absence of pus and by the disappearance of fever. The average duration of local care before appropriation of the wound was 8 days, with a minimum of 4 days and a maximum of 16 days. A secondary wound suture at the site of masking was performed under local anaesthesia (n = 12) and under general anaesthesia (n = 4). In the case of intra-abdominal suppuration, recovery from laparotomy was indicated. An abdominal toilet was then performed, followed by drainage of the abdominal cavity. The mean duration of hospitalization after recovery from laparotomy was 9 days, with a minimum of 7 days and a maximum of 22 days. Three deaths were recorded among the 114 patients, which represents a mortality rate of 2.6%.

4. Discussion

The frequency of surgical site infection in our study was 11.8%. This result is similar to that found by other authors who published studies on patients in sub-Saharan Africa [10,11]. Our study confirms the assertion by the World Health Organization that the frequency of SSI is higher in low-income countries. Indeed, the frequency of SSI in surgery departments is approximately 6% in Europe [3,12]. It should be noted, however, that the types of surgery performed in surgical departments differ from one hospital to another, which makes comparisons of frequencies difficult. The prevalence of surgical site infections is higher after interventions in the abdomen and perineum [12]. Like other authors from Africa, we found a substantial predominance of SSI in women. This finding is quite different from what has been reported in Europe where there is no relative risk related to sex [13,14].

We also highlighted other socio-demographic risk factors such as geographical origin and low socio-economic level. These demographic factors are almost exclusively reported in African series [10,11]. In sub-Saharan Africa, patients in precarious financial situations often opt for traditional medicine and self-medication. They are likely to have experienced complications by the time they arrive at the hospital. These socio-demographic factors are not found in the European and Asian series since social security programs ensure access to care for all [12].

In our series, the risk of SSI was higher in emergency surgery compared with scheduled surgery (16.7% vs 4.6%, p <0.001). The risk was also higher in contaminated surgery than in clean surgery. These risk factors, which are related to the urgency of the intervention and the initial contamination of the surgical site, are universally found in both Africa and Europe [15,16]. Other risk factors described in the literature such as depilation, antibiotic prophylaxis, length of preoperative stay and duration of surgery were not evaluated in our study.

The pathogens involved in our study were exclusively bacteria. According to the literature, bacteria are the main agents responsible for surgical site infections, as the involvement of fungi in SSI is rare [6,17]. E coli was the most implicated germ in our study. In Europe, South America and parts of Africa, a predominance of Staphylococcus aureus and Klebsiella aerogenes is seen [11,12,18]. The predominance of E. coli in our context can be explained by the frequency of abdominal surgery, especially peritonitis, due to digestive perforation. At our hospital, most cases of peritonitis were due to ileal perforation, which is a frequent complication of typhoid fever in a tropical environment. Typhoid fever is an endemic infectious disease in the rural environments of Burkina Faso. This variety of peritonitis leads to an opening in the digestive tract, which in turn results in massive contamination of the peritoneal cavity and the surgical wound by intestinal flora, particularly E. coli. The predominance of non-MDR bacteria, especially non-MDR Staphylococcus aureus, suggests contamination from the bacterial flora of the patient or surgeon. It would therefore be necessary to review the entire chain of preparation of the surgical site, particularly through an introduction of this practice into our department, and in particular, the practice of non-depilation of patients.

5. Conclusion

Our study found that the frequency of surgical site infections was high in rural Burkina Faso. The microbes involved were mostly endogenous bacteria. The unique aspect of our situation is the existence of socio-demographic risk factors such as gender, geographical origin and socio-economic status. Other risk factors that are commonly reported in the literature, such as the adequacy of preoperative antibiotic prophylaxis and the absence of preoperative depilation, deserve to be evaluated to help reduce the frequency of postoperative infections in Africa.

Acknowledgements

We acknowledge Si Simon TRAORE who contributed new analytic tools

Statement of Competing Interests

The authors have no competing interests

List of abbreviations

US $: United States dollar

SSI: surgical site infection

Declarations

Ethics approval and consent to participate

Regarding ethics, this study was authorized by the National Ethics Committee for Health Research in Burkina Faso. For each patient included, epidemiological, clinical, therapeutic and evolutionary data were collected in survey form and were based on clinical and operating records. Informed consent was obtained from all participants or from their legal representatives.

Authors’ Contributions

SO and JLK contributed equally to this work; they designed the research

EO and ID Performed the research

SO and EO Analysed the data

MZ and ID Contributed new analytic tools

Informed Consent Statement

All involved patients or their legally authorized representatives gave their informed consent prior to study inclusion.

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