International Journal of Advanced and Integrated Medical Sciences

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Surgical Site Infections in a Rural Teaching Hospitalof North India
Surgical Site Infections in a Rural Teaching Hospitalof North India
1Rajesh K Abbey, 2Manjul Mohan, 3Nitin Malik, 4Rohit Tiwari, 5Shashank Nahar
1Professor, 2Assistant Professor, 3Senior Resident, 4,5Resident
1-5Department of General Surgery, Rohilkhand MedicalCollege & Hospital, Bareilly, Uttar Pradesh, India
Corresponding Author:
Rajesh K Abbey, Professor, Departmentof General Surgery, Rohilkhand Medical College & HospitalBareilly, Uttar Pradesh, India,
Phone: +919418095677,
Aims and objectives: Surgical site infections (SSIs) are one ofthe most important causes of health care-associated infections.Understanding SSI reduces the social and economic burden ofa hospital and society. In this context, we evaluated the variousaspects of SSI in our institution, Rohilkhand Medical College &Hospital (RMCH), which is a tertiary care teaching hospital inrural Uttar Pradesh in North India.
Materials and methods: This prospective study was conductedin the Department of General Surgery, RMCH, Bareilly,Uttar Pradesh, India. A total number of 1,498 patients admittedfor surgical procedures with effect from November 1, 2016 toDecember 31, 2016, formed the subjects of the present study.All operated cases during the above period, including majorand minor, emergency and elective, laparoscopic and openprocedures were included in the present study. Data so obtainedwere analyzed statistically. The Centers for Disease Controland Prevention, USA criteria were used for defining the wound.Sample swabs were collected from the first dressing and up to 2to 4 weeks postoperatively. Samples were processed for aerobicand anaerobic flora, and the antibiotic sensitivity of the isolateswas also performed.
Results and discussion: The SSI rate in the present study was8.67%. Significantly higher incidence of SSI was detected withincreasing age. The SSI rate in case of emergency surgerieswas more (27.7%) as compared with routine/elective surgeries(6.3%). The higher incidence (18.75%) of SSI was detected inpatients having preoperative hospital stay of more than 7 days,and the maximum incidence (15.7%) was observed in patientshaving longer postoperative hospital stay of more than 10 days.Dirty wounds had the highest incidence of SSI (53.45%). Theincidence of SSI increased with duration of surgery, order ofsurgery, and with the increasing duration of postoperativedrains. Staphylococcus aureus was the commonest isolate(32.30%) followed by Escherichia coli (39%).
Conclusion: Though the incidence of SSI in the present studywas slightly low as compared with similar reports from otherinstitutions of the country, more rational antibiotic policy andmore stringent infection control measures are needed.
Keywords: Centers for disease control and prevention criteria,Hospital stay, Surgical drains, Surgical site infections.
How to cite this article: Abbey RK, Mohan M, Malik N, Tiwari R,Nahar S. Surgical Site Infections in a Rural Teaching Hospitalof North India. Int J Adv Integ Med Sci 2017;2(1):11-16.
Source of Support: Nil
Conflicts of Interest: None


The Centers for Disease Control and Prevention's (CDC)definition of surgical site infections (SSIs) states that infectionsoccurring only within 30 days of surgery (or withina year in case of implants) should be classified as SSIs, andalso the infection should appear to be related to the operation.1-4 The SSIs are the third most frequently reportednosocomial infections, accounting for 14 to 16% of all theinfections,4 The SSIs are further classified as being eitherincisional or organ/space infections. Incisional SSIs arefurther divided into superficial and deep incisional SSIs.

A system of classification for operative wounds,i.e., based on degree of microbial contamination wasdeveloped by the US National Research Council groupin 1964.5 Four classes of wounds, with an increasingrisk of SSIs, were described, i.e., clean, clean-contaminated,contaminated, and dirty. Since the introductionof routine prophylactic antibiotic use, infection rates inthe most contaminated group have reduced drastically.Infection rates in the US National Nosocomial infectionsurveillance system hospitals were reported to be clean(2.1%), clean-contaminated (3.3%), contaminated (6.4%),and dirty (7.1%).6 However, Indian studies consistentlyshow higher rates of SSIs ranging from 4.2 to 30%.5-9 Thisvariability in estimates is consistent with the differencesin the characteristics of the hospital populations, theunderlying diseases, differences in clinical procedures,the extent of the infection control measures, and also thehospital environment. Further, infection with multidrugresistantorganisms constitutes a serious threat to surgicalpatients. It has been observed that failure of hospitalhygiene/aseptic measures and overuse of antibioticsare responsible for high antimicrobial resistance amongpathogens.


The present prospective study was undertaken, as theproblem of SSIs remains largely unexplored with lack inadequate basic data for future comparisons, particularlyin a tertiary care teaching hospital in a rural setup ofNorth India. Hence, in the larger interest of benefitingpatient care, this study was taken up in RohilkhandMedical College & Hospital (RMCH), Bareilly, UttarPradesh, India, which is a teaching hospital providing tertiarylevel medical care in a rural background of westernUttar Pradesh, North India, with the following objectives:
  • To estimate the incidence and pattern of SSIs in thistertiary care rural teaching hospital in the Departmentof General Surgery.
  • To study the various factors that influence SSIs.
  • To evaluate the frequencies of various pathogenscausing SSIs with their antibiotic resistance patterns.

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The present prospective study was conducted in theDepartment of General Surgery, RMCH, Bareilly, UttarPradesh, India, from November 1, 2016 to December 31,2016, on all the patients who underwent surgical proceduresduring this period. The detailed history regardingthe personal particulars of the patients, associated comorbidconditions, the type of surgery (emergency/elective),pre- and postoperative hospital stay, duration of surgery,order of surgery, presence of surgical drain and its durationwere recorded in the individual proforma. TheCDC criteria were used for defining the type of surgicalwounds as clean (class I), clean-contaminated (class II),contaminated (class III), and dirty (class IV).3,4 Thecumulative incidence of SSIs was expressed as infectionrate - the number of patients with SSIs per 100 operatedpatients. The SSI rates for all the four categories werealso determined.Samples in the form of swabs were collected asepticallyat the time of the first dressing, 8 to 10 days andthen 2 to 4 weeks after the surgery from the woundshaving serous or purulent discharge, showing signs ofinflammation, or from the wounds that dehisced spontaneously.All the samples were processed aerobicallyand anaerobically. One of the swabs was used to makesmears, and Gram's staining was done to ascertain themorphological form of bacteria present. The other swabwas cultured on blood agar and MacConkey's agar. Theetiological agents were identified by their morphologicaland biochemical characteristics. Antibiotic sensitivity ofthe isolates was done by the modified Stokes' disk diffusionmethod, and antibiotic sensitivity patterns wereobserved, analyzed, and recorded. Patients were followedup for a period of 30 days after the surgical procedure.The observations were recorded; all the results weretabulated and analyzed by using student's t-test for age,duration of hospital stay, elective vs emergency surgery,wound classification (CDC criteria), drainage, order, andduration of surgery.

RESULTS AND DISCUSSIONElective surgery was performed in 1,332 (88.92%) andemergency surgery in 166 (11.08%) patients. A total of1,498 patients were operated in the Department of GeneralSurgery over the study period. The cumulative infectionrate was 8.67% as 130 patients developed SSIs out of atotal of 1,498 patients.Age and SexIn the present study, 690 (46.1%) were male and 808 (53.9%)were female patients. The male patients who developedSSI were 58 (8.4%), and the number of female patients whodeveloped SSI was 72 (8.91%). No statistically significantdifference was observed in the rates of SSIs among maleor female patients in the present study (p > 0.05). However,the incidence of SSIs was found to increase significantly(p < 0.01) with increase in age group of patients. Theincidence of SSI was found to be more than four timesin patients aged >56 years as compared with the patientsbetween age group 16 and 25 years (Table 1). The resultsare consistent with the available literature.10Duration of Hospital StayPeriod of pre- as well as postoperative hospital stay werealso studied. Duration of preoperative hospital stay wasconsidered only for elective surgeries for obvious reasons.As the duration of hospital stay increased, the rate of SSIsalso increased. Patients with preoperative hospital stay of>7 days had more than four times incidence of SSI as comparedwith those having hospital stay of 1 day; however,the results were not statistically significant (p > 0.05)(Table 2). On the contrary, patients having postoperativehospital stay of >10 days had almost five times incidenceof SSI compared with those of hospital stay of < 2 days,and the results were statistically significant (p < 0.05)(Table 3). Can we ascribe it to the increased chances ofhospital-acquired infections in these patients havinglonger stay? It is also understandable that patients whosepostoperative hospital stay was longer, obviously hadmore morbidity, as complications and comorbid conditionswere seen more in these patients.

Table 1: Age distribution
Surgical Site Infections in a Rural Teaching Hospital of North India
Patients < 15 years of age were not included; p < 0.001, highlysignificant (t = 6.7093; df = 7; Standard error of difference = 40.891)

Table 2: Preoperative hospital stay
Surgical Site Infections in a Rural Teaching Hospital of North India
p > 0.05, not significant (t = 1.7466; df = 3; Standard error ofdifference = 235.317)


Surgical Site Infections in a Rural Teaching Hospital of North India

Table 3: Postoperative hospital stay
Surgical Site Infections in a Rural Teaching Hospital of North India
p < 0.05, very statistically significant (t = 5.6191; df = 5; Standarderror of difference = 59.885)

Table 5: Surgical site infection according to surgical proceduresin elective surgeries
Surgical Site Infections in a Rural Teaching Hospital of North India

Elective vs Emergency Surgery and CDC Criteria

Incidence of SSIs was also found to be more in emergencysurgeries [46 (27.7%)], as compared with routine/electivesurgeries [84 (6.3%)]. The incidence of SSI also increasedfrom clean to dirty wounds; however, the results were notstatistically significant (p > 0.05) (Table 4). A total of 1,332(88.91%) patients underwent elective surgery, whereas 166patients (11.09%) underwent emergency surgery (Table 5).Among the 166 emergency surgeries performed, 94were exploratory laparotomies, and SSI was observedin 24 (25.53%) of these patients. Number of patients whounderwent emergency appendectomies was 72, and outof these, 22 (30.55%) patients developed SSI. Incision anddrainage of abscesses and debridement/amputation donein emergency were excluded from this category, sincethese were considered to be dirty surgeries.

Table 4: Incidence of SSI as per the CDC criteria ofclassification of surgical wounds
Surgical Site Infections in a Rural Teaching Hospital of North India
p > 0.005, not significant (t = 1.4687; df = 5; Standard error ofdifference = 232.525)

Table 6: Incidence of comorbidities
Surgical Site Infections in a Rural Teaching Hospital of North India

Various comorbidities were also found and studiedin our patients (Table 6). Of the 130 patients who developedSSIs, 38 (29.23%) were diabetic (diabetes mellitustype II). A total of 10 (26.31%) diabetic patients whoentered in our study developed SSIs; 28 (21.54%) patientswho developed SSIs had coexistent chronic obstructivepulmonary disease (COPD); 22 (16.92%) patients whodeveloped SSIs had coexisting ischemic heart disease(IHD)/hypertension. Only 42 (32.31%) patients havingno comorbid conditions developed SSI.

Duration and Order of Surgery

There was a statistically significant increased incidence(p < 0.01) of SSI in patients having longer duration ofsurgery (p < 0.01) (Table 7) and increasing order of surgery(p < 0.05) (Table 8). The incidence of infection rates withincreasing order of surgeries (sequence in which theoperations were undertaken during an elective operativesession) was considered only for the elective/routinesurgeries and not for the emergency surgeries, for theobvious reasons.

Table 7: Duration of surgery
Surgical Site Infections in a Rural Teaching Hospital of North India
p < 0.05, significant (t = 6.6484; df = 3; Standard error of difference= 71.346)

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Table 8: Order of surgery
Surgical Site Infections in a Rural Teaching Hospital of North India
p < 0.05, significant (t = 5.6869; Standard error of difference =54.570)

Table 9: Duration of drainage
Surgical Site Infections in a Rural Teaching Hospital of North India
p < 0.05, significant (t = 1.9552; df = 3; Standard error of difference= 35.973)

Table 10: Antibiotic sensitivity analysis
Surgical Site Infections in a Rural Teaching Hospital of North India

Postoperative Drains

Postoperative drains were placed in 268 (17.89%) patients,of which 58 (21.64%) patients developed SSIs. Drains werenot placed in 1,230 (82.1%) patients, of which 72 (5.85%)patients developed SSIs. Hence, patients with postoperativedrains developed more SSIs compared with thosein whom drains were not placed. Further, the incidenceof SSI exceeded more than five times for patients inwhom drains were kept for >7 days as compared withthe patients with drainage for 1 to 3 days (Table 9). Theresults so observed were found to be statistically significant(p < 0.05), and one of the plausible reasons could bethe drain acting itself as a cause of infection.

Culture and Sensitivity

A single etiological agent was identified and isolated inall the 130 cases of SSIs among a total number of 1,498surgeries. The most commonly isolated organisms wasStaphylococcus aureus in 42 (32.3%) patients followed byEscherichia coli in 31 (23.84%), Enterococcus faecalis in 27(20.77%), Pseudomonas aeruginosa in 19 (14.61%), Klebsiellain 9 (6.93%), and Proteus in 2 (1.54%) patients (Table 10).Gram-negative bacteria were found in 61 (46.93%) isolatesand Gram-positive bacteria were found in 69 (53.07%)isolates. Many of the bacteria isolated were multidrugresistant, but none was found to be resistant to all theantibiotics, for which tests were done (Table 10).

The prevalence rate of SSIs, though preventable,is yet quite high. Different studies from India done atdifferent places have shown SSI rates to vary from 4 to30%.1,2,7-9,11-13 The SSI rates in Indian hospitals are muchhigher than those in the US and European countries(0.5-15%).14,15 The higher infection rates in some Indianhospitals may be mainly due to the not very good setupof these hospitals and the inadequate attention towardbasic infection control measures, including lack of ethicalantibiotic policy of individual hospitals. We observed asignificantly increasing incidence of SSI with the increasingage of patients, which is consistent with the otheravailable reports from the country.8,10,14-17 The SSI ratein this hospital, in the present series, was 8.67%. Thismarginally lower rate in our hospital compared withstudies from other Indian hospitals may be due to thebetter setup and better and strict infection control practicesbeing followed in this hospital. This could also bedue to higher proportion of clean and elective surgeriesin the present study.

Emergency surgeries are associated with higherincidence of SSIs in various studies done worldwide.Similarly, the incidence of SSIs in our study was more inemergency surgeries (27.7%) as compared with routine/elective surgeries (6.3%). Mahesh et al11 also observeda similar SSI rate of 21.05% in emergency surgeries ascompared with 7.61% of cases in elective surgeries. Thehigher rates of infections in emergency surgeries can beattributed to higher incidence of contaminated/dirtywounds, underlying pathology which also precipitatesthe underlying comorbid conditions, which probablycould not be properly managed due to emergent natureof surgery. Inadequate preoperative preparation of theseemergency patients could also be a contributory factor.Clean surgeries like mesh hernioplasty for hernia repairand uncomplicated laparoscopic cholecystectomy areassociated with lower SSI rates as compared with dirtysurgeries like surgery for pilonidal sinus and analprocedures,8,11 as was observed in the present study also(Table 5).


Surgical Site Infections in a Rural Teaching Hospital of North India

Higher incidence of SSIs associated with a longer stayin the hospital reflects not only the severity of illness andcomorbid conditions, but also probably increased colonizationof patients with nosocomial strains existing inthe hospital. Our findings were comparable with thoseof Kamat et al,8 who found that the mean duration ofpostoperative stay in patients with SSI was 9 days. Thepatients with postoperative stay of more than 9 days werefive times more likely to develop SSI. Anvikar et al7 demonstratedthat preoperative hospital stay predisposed anindividual to 1.76% risk of acquiring an infection. With anincrease in preoperative hospital stay, the risk increasedproportionally. A preoperative stay of 1 week increasesthe risk rate to 5%. The probable factors that have beenimplicated in the increase in SSIs with higher order of theelective surgery are excessive contamination of operatingtheater after the earlier operations during the day, schedulingof contaminated surgeries toward the end of operatingsession, decline in aseptic measures at the end ofthe day, and onset of fatigue of operating surgical team.A statistically significant association between the ratesof SSIs and the order of the operation and the durationof the operation have been reported by several studies,including one by Mahesh et al.11 Results of the presentseries (Tables 2 and 3) matched the reported inferences.Present study reflected increase in incidence of SSI (3.6times) with longer duration of drainage. Kamat et al,8 intheir study, also observed that patients with postoperativedrains were 5.8 times more likely to develop SSIscompared with those without drains. This increasedincidence of SSIs with increasing duration of postoperativedrains may be attributed to not only the nature ofoperation necessitating the drainage, but also the drainitself acting as portal of entry for infection. Comorbiditieslike diabetes and COPD have been observed to be significantrisk factors for SSI compared with patients withoutcomorbidities. Suchitra and Lakshmidevi16 have reporteddiabetes as a significant risk factor for SSI. Similar resultsare obtained in the present series.

Most of the organisms located were multidrug resistantin our study, including methicillin-resistant S. aureusand vancomycin-resistant enterococcus species (Table 9).Various authors18-21 have also observed that most commonisolated organism in SSI is S. aureus followed by enterococcusand other bacteria.19-22


The SSIs have always been a major and worrying complicationof surgery and trauma adding to further morbidityand draining of the already limited resources. Factorsstudied in the present study as old age, comorbidity,prolonged hospital stay, prolonged operating time, orderof surgery, prolonged drainage, emergency surgery, thewound class, and wound contamination all contributeto SSI. Isolation of multidrug-resistant organismsunderscores the need for an evidence-based antibioticprescription policy that could promote an ethical andrational use of antibiotics along with intensive infectioncontrol practices in the hospital. Slightly low incidenceof SSI in our study may be attributed to the better setupand better infection control practices, although it mustbe emphasized that more stringent aseptic measuresincluding rational antibiotic policy along with adherenceto basic principles of asepsis and sterilization willbe helpful in lowering the SSI rate further.

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