The hospital-acquired infections (HAIs) encompass a range of infections acquired during hospitalization[1]. Among the HAIs, surgical site infections (SSIs) arise following surgical procedures are increasing world wide, that represent a substantial burden, posing challenges to patient care and healthcare resources [2]. Infections occurring up to 30 days after surgery or occurring up to an year after surgeries in patients receiving implants , affecting either the incision or deep tissue at the operating site often characterized by the invasion of body tissues by disease-causing agents are termed as Surgical site infections (SSIs) or “postoperative wound infections”[3,4,5]. Surgical site Infections (SSIs) remains a significant concern in healthcare settings worldwide. SSIs are often associated with increased stay in hospital, increased patient morbidity & mortality along with high healthcare costs, making them a critical focus of research and preventive efforts[6,7]. Despite advancements in medical practices and infection control measures, SSIs persist as a formidable clinical challenge in most developing countries. The degree of characterization is based on their multifactorial etiology, stemming from factors such as surgical techniques, patient-specific variables (risk factors), vigilance criteria used, nature of data aggregation and healthcare practices. In most Instances the patient's own endogenous flora play a role in developing SSI in many surgeries. SSIs also contribute to operation-related mortality, despite occurring recurrently in cutaneous incisions [2,8]. SSI are influenced by factors such as inadequate hand hygiene, improper skin preparation, suboptimal antibiotic use and the nature of surgical procedures [9]. Patient - specific risks may include smoking, immunosuppressive drugs, anemia, advanced age, poor nutrition, diabetes, hypertension, tuberculosis and prolonged hospital stays [10,11,12] Disseminating timely data on surveillance , treatment cost  & the impact of drug-resistant organisms to health care administrators, clinicians and other decision makers is an irreplaceable & effective tool for prevention and control of HAIs [13]. Understanding the intricate  interplay of these factors is essential for devising effective strategies to reduce SSI incidence thereby to improve patient outcomes. Hence the present study aimed to determine the prevalence of SSI, its microbiological profile and antimicrobial susceptibility pattern in patients undergoing abdominal surgeries.

A prospective hospital based observational study conducted over a period of one year, involving patients who underwent abdominal surgeries in Mahatma Gandhi Institute of Medical Sciences, Jaipur from April 2017 to April 2018 . The Pus samples / wound swabs were collected from wounds at surgical sites, post abdominal surgeries presenting with clinical signs of infection. The Pus Samples or wound swabs were aspirated with a sterile syringe from the wound or collected either on sterile cotton swab  and  subjected to routine microbiological investigations such as Microscopy : Grams staining and standard bacterial culture methods : following inoculation on to Blood agar, Chocolate agar & Mac conkey agar  as per standard protocols and incubated for 24 -48 hours at 37°C aerobically for the isolation [13]. All the isolates were further processed for bacterial identification and antimicrobial  susceptibility pattern following standard microbiological procedures using the Vitek-2 Compact instrument (automated method for Bacterial Identification & Antimicrobial susceptibility testing). The data was collected in a specially designed Case Recording Form [CRF] for recording the history and consolidating all the relevant data required.

Study Participants: Only adult patients of age group >18 yrs who underwent emergency or elective  abdominal surgery at Mahatma Gandhi Hospital, Jaipur were included. All necessary baseline details regarding preoperative preparation, intra operative information & postoperative examination were recorded .  All cases included were diagnosed for postoperative wounds as per CDC criteria & documented. Any Patient with repeat abdominal surgery at the same site within 30 days were excluded from the study.

A total of 3358 abdominal surgical cases were included this study based on the inclusion & exclusion criteria. Of these nearly 53 patients developed wounds at the surgery site, among those 36(67.9%) were males and 17(32.1%) were females. Among various  abdominal surgeries SSI rate was found to be high in total abdominal Hysterectomy & X-LAP surgeries i.e, 4.0% & 3.7% respectively (CHART No.1). As per the CDC criteria, Out of 53 cases with SSI; nearly 18(33.96%) were of superficial incisional SSI type, deep incisional SSI was found in 27(50.94%) cases, whereas organ/space SSI was seen in 8(15.09%) cases (CHART No.2). The total incidence of SSI assessed by wound classification as: Clean – 22, Clean contaminated – 4, Contaminated – 27, Dirty – 0. Majority of patients with SSI i.e,( 48 cases ) 90% were anemic in this study,  None of the patient was diabetic nor had h/o diabetes in this study. SSI was widely observed in age group between 40 – 70 years among the study participants.   The microbiological analysis revealed a diverse range of pathogens, including 56.6% E.coli, 15.1% Klebsiella pneumoniae, 11.3% Staphylococcus species, 5.7% Pseudomonas aeruginosa, 9.4% Acinetobacter species, 1.9% Enterobacter species. Notably, E. coli 56.6% was the most frequently isolated pathogen (CHART No.3).

CHART No.1: SURGICAL SITE INFECTION RATES IN VARIOUS ABDOMINAL SURGERIES.

CHART No.2: DISTRIBUTION OF SSI TYPES IN ABDOMINAL SURGERIES.

CHART No.3: DISTRIBUTION OF MICROORGANISMS ISOLATED FROM SSIS IN VARIOUS ABDOMINAL SURGERIES.

Table  1 & 2 : illustrates the drug sensitivity pattern to the commonly used antimicrobials against Gram Negative bacteria & Gram Positive bacteria respectively. Staphylococcus spp demonstrated lowest sensitivity to Erythromycin & Amoxycillin- clavulanic acid i.e, 33.3%. comparatively to Levofloxacin, Ciprofloxacin , Co-trimoxazole i.e, 66.6% & Tetracycline (83.3%). The sensitivity of Staphylococcus spp isolated was fairly high to the broad spectrum antibiotics like Tetracyclines, Tigecycline and Teicoplanin. 100% sensitivity was recorded towards Gentamicin, Linezolid, Tigecycline & Teicoplanin. About 50% of the staphylococcus spp isolated were MRSA (Table No.2). E.coli isolates showed fairly good 70-76.6% sensitivity to Carbapenems  and 53.3 -73.3% sensitivity to Aminoglycosides. The Klebsiella spp isolated showed very low to nil sensitivity to most antibiotic classes such as 3^rd & 4^th generation Cephalosporins, Aminoglycosides, Fluroquinolones & Carbapenems. Majority of Klebsiella spp i.e, 75% isolated in this study were MDR. The Pseudomonas spp showed low sensitivity to 3^rd & 4^th generation Cephalosporins (33.3%) comparatively to Aminoglycosides, Fluroquinolones & Carbapenems (100%). Sensitivity to the tested antibiotics was very low in Acinetobacter spp. ,only 20% of  Acinetobacter spp.  were found sensitive to Amikacin, Piperacillin tazobactum & Imipenem. Nearly 60% of Acinetobacter spp were MDR in this study. (Table No.2).

Table No.1 : DRUG SENSITIVITY PROFILE OF GRAM NEGATIVE ISOLATES (%)

*- Multi Drug Resistant Organisms.

Table No.2 : DRUG SENSITIVITY PROFILE OF GRAM POSITIVE ISOLATES (%)

The overall rate of SSI in abdominal surgery was 1.58%, with current preoperative protocol for SSI prevention , the SSI rate was very low. This correlates with the study done by Vikas Mishra et al from Kanpur  i.e. 1.8% [14]. This is in agreement with two other Indian studies on surgical wounds conducted in Uttarakhand and Aurangabad, which showed almost similar infection incidences of 5% and 6%, respectively [15,16]. Studies has reported SSI in abdominal surgeries between 3.4 % and 36.1% in India [17,18,19,20]. In this study SSI rate was comparatively low i.e 1.58% compared to study by Maitreyee save et al, reported 19.3% in abdominal surgeries conducted between 2017 to 2019 in pune . A combination of bacterial, patient & local factors contribute to development of SSI, hence the difference in SSI rates [1]. Higher infection rate was observed in Male patients 67.92% than females 32.08%. Similar pattern was seen in the study by Victor Odhiambo Dinda, at Nairobi, 75.9% in males and 24.1% in females [21]. Older patients due to high levels of catabolic activity, weaker immune system ,  associated co-morbidities heal slowly and get more prone to develop SSI [22,23,24]. A number of factors contribute to SSI such as previous illness, patient’s immune status, hypertension, diabetic status, anemia, pre & post operative care , infection control practices, duration of surgery etc.,[1]

Characterized by the CDC criteria, of the 53 cases; superficial SSI was found in 18 cases i.e. 33.96%, deep incisional SSI  in 27 cases i.e. 50.94%  whereas organ/space SSI in 8 cases 15.09%.The rates of clean, clean-contaminated and contaminated were 41.51%, 7.54 % and 50.94% respectively. Preoperative antibiotics were prescribed in most of the patients except few emergency surgical procedures. Third generation cephalosporin was used in surgeries that are clean, clean-contaminated, contaminated or dirty procedures as preoperative prophylaxis. Periodic assessment of antibiotic resistance patterns and the strategic dissemination of pertinent data are indispensable elements in addressing the rise of drug-resistant organisms. The colon contains a huge number of organisms, mainly anaerobes, Enterobacteriaceae and Enterococci spp. There is therefore a potential for infection if there is spillage of bowel contents during surgery. The duration of surgery also accelerates the wound susceptibility to microorganisms thereby increasing the exposure time and reduced antibiotics concentration in tissues.  There is good evidence that single dose preoperative antibiotics, do reduce the incidence of wound infection, though there is still debate about the best regimes & re-administration recommended for prolonged surgeries[25,26]. Comparative review of pathogens isolated from SSI in from various studies is illustrated in (Table No.3). Microbiological analysis of SSI revealed a diverse range of pathogens, including 56.6% E.coli, 15.1% Klebsiella pneumoniae, 11.3% Staphylococcus species, 5.7% Pseudomonas aeruginosa, 9.4% Acinetobacter species, 1.9% Enterobacter species. Notably, E. coli was the most frequently isolated pathogen. 56.6%. The patients indigenous microbial flora to be blamed for the existence of enteric pathogens isolated from SSI or infection sites [13].

Table No.3: COMPARATIVE REVIEW OF PATHOGENS ISOLATED FROM SURGICAL SITE INFECTION .

Antimicrobial sensitivity testing showed the most effective drugs against Staphylococcus spp were broad spectrum antibiotics like Tetracyclines, Tigecycline and Teicoplanin i.e, 100% sensitivity was recorded towards Gentamicin, Linezolid, Tigecycline & Teicoplanin. About 50% of the Staphylococcus spp isolated were MRSA and lowest sensitivity was observed towards Erythromycin & Amoxycillin- clavulanicacid i.e, 33.3%.This study had important clinical implication for our hospital decision making on antibiotic prescription towards Gram positive bacteria. The level of sensitivity was significantly low in Gram negative bacteria isolated in this study. Klebsiella spp isolated showed very low to nil sensitivity i.e,12.5% to 25% to most antibiotic classes. The Pseudomonas spp showed low sensitivity to 3^rd & 4^th generation Cephalosporins (33.3%) comparatively to Aminoglycosides, Fluroquinolones & Carbapenems (100%). Majority of Klebsiella spp (75% ) & Acinetobacter spp. (60%)  isolated in this study were MDR. E. coli showed (53.3% - 76.6%) sensitivity to Aminoglycosides & Carbapenems respectively. Several studies has observed decrease in sensitivity to wide class of routinely used antibiotics in gram negative bacteria. A larger issue on a worldwide is the emergence of antimicrobial resistance among bacteria, which is often attributed to the widespread prescription of antimicrobials, that creates strong selection pressure [13,30,31]. The limitation of the present study was that anaerobic culture on pus or wound swabs were not done, hence anaerobic pathogens responsible for SSI in abdominal surgeries couldnot be determined.

The prevalence of SSI in abdominal surgery was 1.58% in this study, This study provides a comprehensive insight into the microbiological profile of SSIs following abdominal surgeries and underscores the importance of understanding local antibiotic resistance patterns. Despite use of prophylactic antimicrobials and sterilizing surgical procedures, SSI remains a major clinical concern. Periodic assessment of the resistance patterns to the commonly used antibiotics is highly recommended.

Inspection, documentation of infection actively & prospectively is an important tool for understanding the degree and distribution of nosocomial infections. Addressing the risk factors through strict infection control and personalized patient care is crucial for reducing SSIs and enhancing surgical outcomes. Implementing advancement of SSI prevention strategies ultimately increase patient safety in surgical settings. The antibiotic sensitivity patterns highlighted very low to nil sensitivity & varying degrees of resistance among the isolated microorganisms, emphasizing the need for targeted and judicious antibiotic therapy. Further research is warranted to explore strategies for infection prevention and control in this patient population. Healthcare system administrators and decision-makers play a pivotal role in prioritizing the actions such as ensuring infection control practices, the efficacy of antimicrobial stewardship programs , appropriate pre and  post operative patient care which ultimately reduce the SSI burden and mitigate the impact of antibiotic resistance on patient care and healthcare costs.

T

1. Save M, Khadilkar R, Shah P, Shiva R. A study of incidence and factors determining the occurrence of surgical site infection in abdominal surgeries. International Surgery Journal. 2020 Feb;7(2):520.
2. Leaper DJ. Surgical-site infection. Journal of British Surgery. 2010 Nov;97(11):1601-2.
3. Amoran, O. E., A. O. Sogebi, and O. M. Fatugase. "Rates and Risk Factors Associated with Surgical Site Infections in a Tertiary Care Center in South-Western Nigeria." (2013).
4. Awad SS. Adherence to surgical care improvement project measures and post-operative surgical site infections. Surgical infections. 2012 Aug 1;13(4):234-7.
5. Donham RT, Mazzei WJ, Jones RL. Association of anesthesia clinical directors' procedural times glossary: glossary of times used for scheduling and monitoring of diagnostic and therapeutic procedures. American Journal of Anesthesiology. 1996;23.
6. Allegranzi B, Nejad SB, Combescure C, Graafmans W, Attar H, Donaldson L, Pittet D. Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis. The Lancet. 2011 Jan 15;377(9761):228-41.
7. Bates DW, Larizgoitia I, Prasopa-Plaizier N, Jha AK. Global priorities for patient safety research. Bmj. 2009 May 14;338.
8. Burke JP. Infection control-a problem for patient safety. New England Journal of Medicine. 2003 Feb 13;348(7):651-6.
9. Zaboli Mahdiabadi M, Farhadi B, Shahroudi P, Mohammadi M, Omrani A, Mohammadi M, Hekmati Pour N, Hojjati H, Najafi M, Majd Teimoori Z, Farzan R. Retracted: Prevalence of surgical site infection and risk factors in patients after knee surgery: A systematic review and meta‐analysis. International wound journal. 2024 Feb;21(2):e14765.
10. Hariom Sharan, Hariom Sharan, A. P. Mishra, and Ritu Mishra Ritu Mishra. "Predictors of surgical site infections in rural Kanpur, India." (2013): 2309-2314.
11. Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infection Control & Hospital Epidemiology. 1992 Oct;13(10):606-8.
12. Owens CD, Stoessel K. Surgical site infections: epidemiology, microbiology and prevention. Journal of hospital infection. 2008 Nov 1;70:3-10.
13. Ratnesh K, Jha S, Arya A. Clinical and bacteriological profile of abdominal surgical site infections in an Indian Hospital. Bioinformation. 2022 Oct 31;18(10):962.
14. Vikas mishra, Ambika bhatiani, nidhi pal, ashish chandna."Bacteriological profile of surgical site infections and their antimicrobial susceptibility pattern at tertiary care centre in kanpur". Jemds.com original research article j. Evolution med. Dent. Sci. "oct. 13, 2016";/ vol. 5/ issue 82/ page 6141.
15. Sahu SK, Jaspreet Singh, Praveendra Kumar, Pratima Gupta, "Superficial Incisional SSI in elective abdominal surgeries- a Prospective study". The Internet J of Surgery; "2011"; 26(1).
16. Hernandez K, Ramos E, Seas C, Henostroza G, Gotuzzo E. Incidence of and risk factors for surgical-site infections in a Peruvian hospital. Infection Control & Hospital Epidemiology. 2005 May;26(5):473-7.
17. Raka L, Krasniqi A, Hoxha F, Musa R, Mulliqi G, Krasniqi S, Kurti A, Dervishaj A, Nuhiu B, Kelmendi B, Limani D. Surgical site infections in an abdominal surgical ward at Kosovo Teaching Hospital. The Journal of Infection in Developing Countries. 2007 Dec 1;1(03):337-41.
18. Razavi SM, Ibrahimpoor M, Sabouri Kashani A, Jafarian A. Abdominal surgical site infections: incidence and risk factors at an Iranian teaching hospital. BMC surgery. 2005 Feb 27;5(1):2.
19. Kamat US, Fereirra AM, Kulkarni MS, Motghare DD. A prospective study of surgical site infections in a teaching hospital in Goa. Indian Journal of Surgery. 2008 Jun;70(3):120-4.
20. Gomila A, Carratalà J, Camprubí D, Shaw E, Badia JM, Cruz A, Aguilar F, Nicolás C, Marrón A, Mora L, Perez R. Risk factors and outcomes of organ-space surgical site infections after elective colon and rectal surgery. Antimicrobial Resistance & Infection Control. 2017 Apr 21;6(1):40.
21. Dinda, Victor Odhiambo. "Surveillance of surgical site infections at the Aga Khan University Hospital, Nairobi." PhD diss., 2014.
22. Geubbels EL, Mintjes-de Groot AJ, Van den Berg JM, de Boer AS. An operating surveillance system of surgical-site infections in The Netherlands: results of the PREZIES national surveillance network. Infection Control & Hospital Epidemiology. 2000 May;21(5):311-8.
23. Munez E, Ramos A, de Espejo TÁ, Vaqué J, Sánchez-Payá J, Pastor V, Asensio Á. Microbiology of surgical site infections in abdominal tract surgery patients. Cirugía Española (English Edition). 2011 Nov 1;89(9):606-12.
24. Kaye KS, Anderson DJ, Sloane R, Chen LF, Choi Y, Link K, Sexton DJ, Schmader KE. The effect of surgical site infection on older operative patients. Journal of the American Geriatrics Society. 2009 Jan;57(1):46-54.
25. Leong G, Wilson J, Charlett A. Duration of operation as a risk factor for surgical site infection: comparison of English and US data. Journal of Hospital Infection. 2006 Jul 1;63(3):255-62.
26. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP. Clinical practice guidelines for antimicrobial prophylaxis in surgery. American journal of health-system pharmacy. 2013 Feb 1;70(3):195-283.
27. Negi Vikrant, Pal S, Juyal D, Sharma MK, Sharma N. Bacteriological profile of surgical site infections and their antibiogram: A study from resource constrained rural setting of Uttarakhand state, India. Journal of clinical and diagnostic research: JCDR. 2015 Oct 1;9(10):DC17.
28. Malik Asif Zafar, Ali Qasim. Surgical site infections after elective surgery in Pakistan: Surgipak Study. Journal of Rawalpindi Medical College. 2015 Dec 30;19(3).
29. B Ramana, R Jayaprada , N Rama Krishna, D Rakesh, K Krishna Karthik.."Microbiological profile and antibiotic sensitivity patterns of surgical site infections in the urology department at a tertiary care Hospital, Tirupati". Journal of Medical Pharmaceutical; "August_2016";177-187.