Surgical site infections (SSIs) affect the safety of surgical care and are particularly problematic and prevalent in low and middle Human Development Index Countries (LMHDICs).
Methods:
We performed a systematic review of the existing literature on SSIs after tissue flap procedures in LMHDICs through the PubMed, Ovid, and Web of Science databases. Of the 405 abstracts identified, 79 were selected for full text review, and 30 studies met inclusion criteria for analysis.
Results:
In the pooled analysis, the SSI rate was 5.8 infections per 100 flap procedures (95% confidence interval [CI] 2%–10%, range: 0–40%). The most common indication for tissue flap was pilonidal sinus repair, which had a pooled SSI rate of 5.6 infections per 100 flap procedures (95% CI 2%–10%, range: 0–15%). No fatalities from an infection were noted. The reporting of infection epidemiology, prevention, and treatment was poor, with few studies reporting antibiotic agent use (37%), responsible pathogens (13%), infection comorbidities (13%), or time to infection (7%); none reported cost.
Conclusions:
Our review highlights the need for more work to develop standardized hospital-based reporting for surgical outcomes and complications, as well as future studies by large, multi-national groups to establish baseline incidence rates for SSIs and best practice guidelines to monitor SSI rates.
Get full access to this article
View all access options for this article.
References
1.
MearaJG, LeatherAJ, HaganderL, et al.Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. Lancet, 2015; 386:569–624.
AllegranziB, Bagheri NejadS, CombescureC, et al.Burden of endemic health-care-associated infection in developing countries: Systematic review and meta-analysis. Lancet, 2011; 377:228–241.
4.
ChungCU, WinkJD, NelsonJA, et al.Surgical site infections after free flap breast reconstruction: An analysis of 2,899 patients from the ACS-NSQIP datasets. J Reconstr Microsurg, 2015; 31:434–441.
5.
ClaytonJL, BazakasA, LeeCN, et al.Once is not enough: Withholding postoperative prophylactic antibiotics in prosthetic breast reconstruction is associated with an increased risk of infection. Plast Reconstr Surg, 2012; 130:495–502.
6.
Human Development Report 2015: Work for Human Development. United Nations Development Programme; 2015. hdr.undp.org/en/2015-report (Last accessed August22, 2017).
7.
HanleyJA, Lippman-HandA. If nothing goes wrong, is everything all right? Interpreting zero numerators. JAMA, 1983; 249:1743–1745.
8.
EypaschE, LeferingR, KumCK, TroidlH. Probability of adverse events that have not yet occurred: A statistical reminder. BMJ, 1995; 311:619–620.
9.
MasoodiZ, AhmadI, KhurramF, HaqA. Management of post road traffic accident compound leg defects using fasciocutaneous flaps. J Wound Care, 2013; 22:376–378, 380–382.
10.
JenaA, PatnayakR, SharanR, et al. Outcomes of pectoralis major myocutaneous flap in female patients for oral cavity defect reconstruction. J Oral Maxillofac Surg, 2014; 72:222–231.
11.
BessaSS. Comparison of short-term results between the modified Karydakis flap and the modified Limberg flap in the management of pilonidal sinus disease: A randomized controlled study. Dis Colon Rectum, 2013; 56:491–498.
12.
ShahzadMN, AhmedN, QureshiKH. Reverse flow posterior interosseous flap: Experience with 53 flaps at Nishtar Hospital, Multan. J Pak Med Assoc, 2012; 62:950–954.
13.
El-MarakbyHH, KotbMH. Oncoplastic volume replacement with latissimus dorsi myocutaneous flap in patients with large ptotic breasts. Is it feasible?. J Egypt Natl Canc Inst, 2011; 23:163–169.
14.
SinghR, SinghR, RohillaRK, et al.Improvisations in classic and modified techniques of flap surgery to improve the success rate for pressure ulcer healing in patients with spinal cord injury. Int Wound J, 2013; 10:455–460.
15.
KummoonaRK. Missile war injuries of the face. J Craniofac Surg, 2011; 22:2017–2021.
16.
ShakirovBM. Different surgical treatment of post-burn trophic ulcers of the plantar surface in foot burns. Burns, 2011; 37:1439–1443.
17.
HuijingMA, MarckKW, CombesJ, et al.Facial reconstruction in the developing world: A complicated matter. Br J Oral Maxillofac Surg, 2011; 49:292–296.
18.
ChoudhuryAI, DattaNK, KaiserS, et al.Management of old Tendo Achilles injury by surgical reconstruction with Lindholm technique. Mymensingh Med J, 2010; 19:213–218.
19.
el-KhadrawyO, HashishM, IsmailK, ShalabyH. Outcome of the rhomboid flap for recurrent pilonidal disease. World J Surg, 2009; 33:1064–1068.
20.
LasheenAE, SaadK, RaslanM. Crossed triangular flaps technique for surgical treatment of chronic pilonidal sinus disease. Arch Surg, 2008; 143:503–505.
21.
OparaKO, ChukwuanukwuTO, OgbonnayaIS. Groin flap for coverage of upper extremity defects in Enugu, Nigeria. Niger J Med, 2006; 15:295–297.
22.
KalamMA, FaruqueeSR, KarmokarSK, KhadkaPB. Superficial sural artery island flap for management of exposed Achilles' tendon—surgical techniques and clinical results. Kathmandu Univ Med J (KUMJ), 2005; 3:401–410.
23.
GiesslerGA, FiegerA, CorneliusCP, SchmidtAB. Microsurgical reconstruction of noma-related facial defects with folded free flaps: An overview of 31 cases. Ann Plast Surg, 2005; 55:132–138.
24.
JoshuaJ, SarkarS. Management of 34 chronic heel sinuses in leprosy, using a modification of a local rotation flap in Kolkata, India. Lepr Rev, 2004; 75:254–265.
25.
SahasrabudheP, PanseN, BahetiB, et al.Reconstruction of complex soft-tissue defects around the knee joint with distally based split vastus lateralis musculocutaneous flap: A new technique. J Plast Reconstr Aesthet Surg, 2015; 68:35–39.
26.
GadreKS, GadreP, SaneVD, et al.Pectoralis major myocutaneous flap–still a workhorse for maxillofacial reconstruction in developing countries. J Oral Maxillofac Surg, 2013; 71:2005.e1-2005.e10.
27.
JepegnanamTS, BoopalanPRJ, NithyananthM, TitusVT. Reconstruction of complete knee extensor mechanism loss with gastrocnemius flaps. Clin Orthop Relat Res, 2009; 467:2662–2667.
28.
JamalA, ShamimM, HashmiF, QureshiMI. Open excision with secondary healing versus rhomboid excision with Limberg transposition flap in the management of sacrococcygeal pilonidal disease. J Pak Med Assoc, 2009; 59:157–160.
29.
DenewerA, SetitA, HusseinO, FaroukO. Skin-sparing mastectomy with immediate breast reconstruction by a new modification of extended latissimus dorsi myocutaneous flap. World J Surg, 2008; 32:2586–2592.
30.
SinghR, PavithranNM. Adipo-fascio-cutaneous flaps in the treatment of pilonidal sinus: Experience with 50 cases. Asian J Surg, 2005; 28:198–201.
31.
SulimanMT. Experience with the seven flap-plasty for the release of burns contractures. Burns, 2004; 30:374–379.
32.
HashmiPM. An experience with free scapular flap for reconstruction of lower extremity defects at Aga Khan University Hospital Karachi. J Ayub Med Coll Abbottabad, 2004; 16:54–57.
33.
SakrM, El-HammadiH, MoussaM, et al.The effect of obesity on the results of Karydakis technique for the management of chronic pilonidal sinus. Int J Colorectal Dis, 2003; 18:36–39.
34.
FaroukO, AttiaE, RoshdyS, et al.The outcome of oncoplastic techniques in defect reconstruction after resection of central breast tumors. World J Surg Oncol, 2015; 13:285.
35.
MegahedMA. Function-sparing tibialis anterior pivoted muscle flap for reconstruction of post-burn and post-traumatic middle-third leg defects with exposed tibia. Ann Burns Fire Disasters, 2011; 24:67–71.
36.
MarchalandJP, OllatD, MathieuL, VersierG. How to cover soft-tissue defects after injuries to the leg in precarious conditions. Eur J Trauma Emerg Surg, 2009; 35:3–9.
37.
Abo SediraM, AminAA, RifaatMA, et al.Locally advanced tumors of the scalp: The Egyptian National Cancer Institute experience. J Egypt Natl Canc Inst, 2006; 18:250–257.
38.
OlaOlorunDA. Abdominal fasciocutaneous flap for upper extremity wound coverage in the developing world: Indications and complications. Trop Doct, 2001; 31:45–46.
39.
SøndenaaK, AndersenE, NesvikI, SøreideJA. Patient characteristics and symptoms in chronic pilonidal sinus disease. Int J Colorectal Dis, 1995; 10:39–42.
40.
Al-KhamisA, McCallumI, KingPM, BruceJ. Healing by primary versus secondary intention after surgical treatment for pilonidal sinus. Cochrane Database Syst Rev, 2010; 1:CD006213.
HarrisonBL, LakhianiC, LeeMR, Saint-CyrM. Timing of traumatic upper extremity free flap reconstruction: A systematic review and progress report. Plast Reconstr Surg, 2013; 132:591–596.
43.
SofiadellisF, LiuDS, WebbA, et al.Fasciocutaneous free flaps are more reliable than muscle free flaps in lower limb trauma reconstruction: Experience in a single trauma center. J Reconstr Microsurg, 2012; 28:333–340.
44.
LoCH, LeungM, BaillieuC, et al.Trauma centre experience: Flap reconstruction of traumatic lower limb injuries. ANZ J Surg, 2007; 77:690–694.
45.
UrbanJA. Cost analysis of surgical site infections. Surg Infect, 2006; 7(Suppl 1):S19–S22.
46.
OlsenMA, Chu-OngsakulS, BrandtKE, et al.Hospital-associated costs due to surgical site infection after breast surgery. Arch Surg, 2008; 143:53–60.
47.
AndersonDJ, PodgornyK, Berríos-TorresSI, et al.Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol, 2014; 35:605–627.
48.
Global Guidelines for the Prevention of Surgical Site Infection. World Health Organization; 2016. www.who.int/gpsc/ssi-guidelines/en/ (Last accessed august24, 2017).
49.
Viet HungN, Anh ThuT, RosenthalVD, et al.Surgical site infection rates in seven cities in Vietnam: Findings of the International Nosocomial Infection Control Consortium. Surg Infect, 2016; 17:243–249.
50.
Ramírez-WongFM, Atencio-EspinozaT, RosenthalVD, et al.Surgical site infections rates in more than 13,000 surgical procedures in three cities in Peru: Findings of the International Nosocomial Infection Control Consortium. Surg Infect, 2015; 16:572–576.
51.
SinghS, ChakravarthyM, RosenthalVD, et al.Surgical site infection rates in six cities of India: Findings of the International Nosocomial Infection Control Consortium (INICC). Int Health, 2015; 7:354–359.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
