Challenges in the Prevention of Surgical Site Infections in India

Abstract

Surgical site infections (SSIs) are health-care-associated infections that burden not only patients undergoing various surgical procedures but the health-care facilities providing care as well. Although preventable, SSIs contribute to complicated and lengthy hospital stays for patients undergoing surgeries, especially in developing countries more than in developed nations. Anticipating and implementing measures to curtail such preventable events in a health-care facility are of utmost importance in providing quality health care. Enhancing and strengthening infection control practices lie in the hands of all health-care workers coming in contact with a patient from the time of admission to discharge. The standard guidelines and protocols are in place by various organizations worldwide on SSI prevention. These guideline-based recommendations are discussed in this review to guide clinicians, microbiologists, infection control specialists, and nurses to excel in safe surgery practices, thereby achieving effective and sustainable patient care. Apart from this, hurdles in our country and ways of handling the same are also discussed.

Introduction

A surgical site infection (SSI) refers to the development of infection at the site of an incision within 30 days after a surgical procedure or within 90 days for some surgeries such as cardiac, breast, implant surgeries, craniotomy, spinal fusion, ventricular shunt, open reduction of the fracture, herniorrhaphy, and bypass graft surgeries. Apart from this recommendation given by the National Healthcare Safety Network, a 30-day follow-up period is advised for superficial incisional SSIs and secondary incisional SSIs regardless of the surveillance period for the primary site.^[1]

SSIs remain a substantial cause of morbidity, prolonged hospitalization, and mortality, and are the most costly health-care-associated infections (HAI) requiring the most frequent readmissions after discharge. SSI results in a substantial increase in mortality rate, especially in low-income developing countries across the world. The incidence of SSIs globally is estimated to be varied with lower SSI rates ranging from 0.9% to 2.1% in Western countries and higher rates ranging from 6.1% to 7.8% in low- and middle-income countries.^[2] These poor outcomes can easily be prevented by understanding the risk factors of SSI. Keeping this in mind, the Asia Pacific Society of Infection Control (APSIC) has put forth guidelines in 2019 for uniform practices to reduce the burden of SSI in low- and middle-income countries aiming at improving the quality of life in patients undergoing surgeries. Multiple studies have been reviewed to arrive at meaningful conclusions and recommendations to prevent SSI. This review was written to highlight various risk factors of SSI and thereby preventive measures which are recommended, experiences, and challenges in the prevention of SSI in health-care facilities.

Risk Factors for Surgical Site Infections

There are various reasons why only certain but not all patients who undergo surgeries develop SSI.

Risk factors for developing SSI can be classified into three: Preoperative (i.e., before the surgical procedure), perioperative (during hospital stay), and postoperative (i.e., after discharge from the hospital) [Figure 1].

Figure 1

Risk factors for the development of SSI. SSI: Surgical site infections

• Preoperative risk factors

• Modifiable risk factors: solely under the patient's control/responsibility. Uncontrolled diabetes mellitus, obesity, smoking, alcohol consumption, and immunosuppression.

Perioperative risk factors

In the perioperative period, good and safe surgical practices at the health-care facility, engineering controls, and stringent infection control practices play a pivotal role in preventing SSI.

Postoperative risk factors

Care in the postoperative period is the most crucial one which lies in the hands of the patients themselves.

1. In general, personal cleanliness and hygiene are necessary at all times after surgery

2. Never touch the wound or dressing with bare, unclean hands

3. Visitor restrictions should be in place to avoid unnecessary exposure to germs carried through people or inanimate objects

4. Clean hands go a long way in preventing infections. A simple handwash using soap and water should be done frequently. As an alternative, an alcohol-based hand sanitizer can also be used if hands are not visibly soiled

5. Frequent cleaning of the patient's surrounding, especially high-touch surfaces, will prevent the colonization of germs in the environment and the formation of biofilms

6. Clean linen and laundry is a mandate. Soiled linen should be removed and washed immediately

7. If the wound dressing is soaked with blood or pus, it requires attention and follow-up with the surgeon according to his/her instructions for review

8. Most importantly, glycemic control before and after surgery is of utmost importance since an increased blood glucose level impairs immune response and delays the wound healing process.

However, in case a person develops SSI which may manifest as pain or tenderness, redness, purulent discharge, and/or swelling at the site of incision, an immediate consultation should be sought.

Based on the level or depth of involvement, an SSI can be classified as superficial, deep, or organ-space SSI. On assessing the wound and type of SSI, the surgeon or an infectious disease consultant provides a treatment plan which may include wound debridement, antibiotic therapy, and/or re-suturing of the wound.

Recommendations of Infection Control Society

The APSIC has formulated guidelines for SSI prevention elaborating evidence-based recommendations for countries in the Southeast Asian region. India is a country with numerous health-care facilities both public and private, modern medicine, and surgical infrastructure advancements. On the other hand, the population density as well as low-income strata has been challenging in controlling HAI. India is also known as the diabetic capital of the world, which is not only a stand-alone risk factor but contributes to other coexisting conditions in worsening the possibility of SSI. The APSIC recommendations for preventive measures are elicited in [Table 1].

Table 1

Recommendations for surgical site infection preventive measures

Impact and Challenges in Future (Indian Scenario)

In India, various studies have mentioned the burden of SSI as a concern in health-care facilities. However, the actual burden of SSI, preventive measures, and fixed protocols to ensure low SSI rates in hospitals all remain a lacuna and a challenge. The true burden of SSI in India or any other developing countries cannot be elicited unless a standard uniform data collection system exists. Data segregation, analysis, and reporting systems have been found to be underestimated and nonuniform across India. A standard centralized governing body for SSI data collection would play an effective role in implementing SSI prevention strategies after highlighting the true burden of SSI in the country. This is the first and foremost challenge in our country. Inconsistent and nonuniform practices, including choice of presurgical prophylaxis, disinfection policy, presurgical screening, and other unhygienic methods, worsen the SSI rates in India. Considering the vast population and varied health-care infrastructure, standard protocols should be implemented uniformly across all health-care facilities irrespective of size (nursing homes and tertiary care centers) and location (urban and rural). This highlights the importance of involving all stakeholders in national infection control discussions to disseminate knowledge and monitor infection rates. Once the true burden of SSI in our country is assessed using standard tools and reporting systems, corrective and preventive actions can be devised to prevent the same. Presurgical, intraoperative, and postsurgical preventive measures should also be standardized and uniformly followed across the country.

Suggestions to Handle Surgical Site Infections Rate in India

The most important measure of a problem statement lies in accurate data on the burden of SSI in India. This mandates the framing of a subdivision of a governing body like the Indian Council of Medical Research. Centers across India both public as well as private must be controlled by such a network in the collection, submission, and analysis of data on SSI across India. Once the true burden is estimated, a uniform surveillance network with stringent protocols to be followed in preventing SSI should be laid down and monitored on a monthly basis. Reports from various parts of the country will reveal good as well as bad practices and underreporting of SSI. Once the data on SSI burden are generated, key problems/root causes may be identified, and preventive actions may be discussed. A uniformity in data collection and preventive measures implementation may be useful in bringing down the SSI burden in India.

Conclusion

The SSI rate in India is undetermined due to the absence of standard reporting to a centralized portal. With available data from various centers across the country, the determination of root causes as well as standardization of preventive measures remains a challenge. International evidence-based recommendations by infection control societies have been discussed in this review. However, a country-wide guideline/recommendation will be appropriate for Indian health-care organizations taking into consideration the vastness and diversity of the same in our country. With evolving knowledge on infection control practices among health-care workers in India, the standardized SSI prevention and monitoring strategies, if implemented, will play a major beneficial role in preventing SSIs among our population.