Researchers found that 358 patients (47.4%) received preoperative antimicrobial prophylaxis (Table 2). According to these data, the duration and timing of antimicrobial prophylaxis did not follow published clinical practice guidelines; doses varied according to each surgeon’s prescription. The most frequent antimicrobial prescribed was ceftriaxone, followed by amikacin. Anaerobic coverage, consisting predominantly of metronidazole, was prescribed in all cases.
Finally, by analyzing the microbiology cultures of the 91 patients diagnosed with SSI in the general surgical service, it was ascertained that 5 (5.49%) were culture negative, and 86 (94.51%) had positive bacterial growth in culture within a 48-hour incubation period. The most common isolates in order of decreasing frequency were: gram-negative bacteria such as enterobacteria, 53.84% (Escherichia coli, 39.56%); Pseudomonas aeruginosa, 17.58%; enterococcus, 8.79%; coagulase-negative Staphylococcus species, 6.49%; and Candida albicans, 3.3%.
In this study population, SSIs occurred in 12% of the total sample (n = 91). Previous studies found that the rate of SSI was 9.5% for colonic surgery and 1.4% for cholecystectomy;24 in 2017, the French national SSI impact survey reported that the rate of SSIs was 0.82% in patients undergoing hernia surgery and 2.03% in those who have an appendectomy.25 The disparity between previous data and the results of this study highlight the importance of further investigations into the relationship between SSI and open abdominal surgery.
In this study, patients who underwent colorectal surgery had the highest SSI rates. This procedure entails the risk of wound contamination by normal flora of the digestive tract. This is relevant because if the wound is dirty and/or contaminated, SSI can ensue if bacterial exposure causes an infection. However, contaminated and dirty wounds were not left open. Instead, during the surgical procedure, the abdominal cavity and subcutaneous tissue were washed multiple times, using multiple wound drainages. The study began by establishing the risk factors associated with SSI. Most patients in this study were between 18 and 40 years old. There are reports that associate SSI with ages older than 60 years9 and identify increasing age as independent predictor of SSI. In this study, the average age of patients with SSI was 41 years old, compared with other studies on SSI in which the average patient age was 50 years.26,27 Because most of the patients in this study were younger adults, it makes sense that the rates of SSI were lower than what has been previously reported.
Women had significantly lower rates of SSI compared with men. In men, androgens have been shown to have a proinflammatory effect on wounds, impairing re-epithelialization, whereas in women estrogens have an anti-inflammatory effect, which could account for this difference.25
Most of the patients were nonsmokers, but those who were smokers were at significantly higher risk of SSI. It has been reported that a smoking habit exerts a negative effect on wound healing through impairment of tissue oxygenation.9,28 Further, comorbidities such as diabetes mellitus, high blood pressure, and obesity previously reported as risk factors29 for SSI were also found to be such in this study. Therefore, prior to undertaking any abdominal surgical procedure, clinicians should know the comorbidities present in every patient and attempt to promote behavior changes such as smoking cessation to decrease the impact these factors can have on postoperative outcomes.
The SSI rate among patients who underwent elective surgery reached 16%; SSI influences 1-year recurrence rates in hernias. However, previous studies have reported a lower frequency of SSI in elective surgeries in those patients who modify their risk factors.30 Again, clinicians must work to reduce SSIs by addressing patients’ comorbidities prior to surgery, improving antimicrobial prescribing protocols, and seeking out the most advisable surgical procedures. It is essential that patient-related factors such as losing weight, smoking cessation, and proper control of chronic diseases prior to surgery are optimized.
Previous reports have shown a significant association between ASA classification and SSI,8,31 which these results also show; in particular, patients in ASA classes III and IV have an increased risk of SSIs. Clinicians should consider the patient’s ASA classification before undertaking surgery. This study did not find that a higher number of people in the operating room during surgery is an independent predictor of SSI. However, these results should be interpreted with caution because other studies32,33 have concluded that there is a statistically significant association between the number of people in the room during the operation and SSI.34 This discrepancy could be explained by the small sample size in this study; further studies are recommended for conclusive outcomes.
This study associates the duration of the operation and SSI. The longer the operation, the higher the probability a patient will acquire an infection because the time of wound exposure is longer. The authors suggest that an adequate methodology using recommendations and strategies to improve adherence to SSI prevention interventions during surgery can control SSI in the operating theater.
Although patients whose microbiology reports showed evidence of SSI had their antimicrobial treatments modified, the authors of this study determined that patients received inadequate antimicrobial treatment not only as preoperative prophylaxis but also during the postoperative period. Providers did not prescribe antimicrobials according to best practices or the correct dosages, timing, or duration of treatment. In some cases, patients lacked the economic resources to buy the indicated antimicrobial; in others, the availability of antimicrobials in the study hospital was limited. Because of these factors, the principles of antimicrobial prophylaxis were not met.
Upon arrival to the hospital, 60% of patients presented with complicated surgical cases; these patients were more likely to have dirty wounds. Histopathologic findings of surgical specimen reports for these patients described advanced evolution of the disease (ie, gangrenous and ruptured).
This study demonstrated no significant association between SSI and patients receiving antimicrobial prophylaxis; nevertheless, preoperative prophylactic antimicrobial administration (within 1 hour before surgery) should be considered an integral part of SSI prevention. The authors recommend facilities develop antimicrobial guidelines regarding these patients.
This study’s authors observed an increasing incidence of ceftriaxone resistance in E. coli isolates responsible for SSIs. Further, the researchers observed high numbers of carbapenem-resistant and fluoroquinolone agents isolates responsible for infection, with imipenem resistance reported for E. coli and Pseudomonas isolates. These findings are relevant to individualizing recommendations for antimicrobial prophylaxis prior to surgical procedures; it is necessary to formulate specific and local guidelines for antimicrobial prophylaxis.
This hospital receives patients from several municipalities; patients often present with complicated diseases. Moreover, patients could only receive the antimicrobials available in the hospital; those infected were treated with a broad-spectrum antimicrobial. The lack of targeted antimicrobial treatment may have influenced the outcomes. Each SSI was associated with additional postoperative days in the hospital and attributable costs, depending on the infecting pathogen.
Among the bacterial species isolated from patients with SSI after abdominal surgery was a predominance of Gram-negative bacilli of gastrointestinal origin (aerobes and anaerobes) together with Gram-positive bacteria such as Staphylococcus and Enterococcus species. These findings were consistent with similar studies in which the marked diversity of potential pathogens involved in these infections highlights the risk of an inadequate treatment approach.35,36
During this study, the authors observed noncompliance with perioperative protocols, such as changing gloves and dressings before closing by the surgeon. In addition, violations to perioperative protocols in the surgical ward were detected, related to the lack of hospital surgical materials and supplies available to care for surgical wounds, suggesting improper handling and wound contamination.
This study included SSIs detected, cultured, and managed on an outpatient basis; the actual overall SSI incidence could have been higher than reported here, because there were patients who underwent outpatient surgery and were lost to follow-up and thus were not recruited. In other words, the uncertainty around the accuracy of postdischarge surveillance has hampered researchers’ ability to get more exact SSI rates.
Finally, the sample size of the present report is small when compared with other studies reporting SSI rates for different procedures.
There is scarce information on SSI surveillance methods in general in the Mexican population. To the authors’ knowledge, this study is the first analysis investigating the risk factors associated with SSI after open abdominal surgery in this population; these results may provide a different perspective to improve the surveillance of SSI by contributing new data to the literature, which is mostly confined to White populations.
The present study also suggests that the lack of discipline in adhering to SSI prevention protocols by surgical team members is a significant intraoperative risk factor, which could be modified by further intervention.
Finally, the findings of the present study are important because in the state of Tabasco, Mexico, hospitals do not implement antimicrobial prophylaxis policies; ideally, the outcomes of this study could encourage the development of such policies. Antimicrobial policy guidelines should be established to improve SSI control before, during, and after any abdominal surgical procedure in the Mexican population.
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Keywords:Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
abdominal surgery; antimicrobials; ASA classification; surgery; surgical site infection; surveillance