Introduction:

The Centers for Disease Prevention and Control (CDC) defined Surgical Site Infection (SSI) as an infection that happens within a month following surgical intervention and includes three types: superficial incisional SSIs (primary & secondary), deep incisional SSIs (primary & secondary) and organ/space SSIs (Kim et al., 2022). According to the Lancet Infectious Disease, Surgical site infections (SSIs) represent a significant global burden to healthcare systems and insurance providers due to increased costs, patient morbidity, and mortality, making them one of the most preventable healthcare-associated illnesses. The most frequent postoperative complication globally, surgical site infection (SSI) places a significant financial strain on both patients and healthcare systems (Allegranzi et al., 2011)(World Health Organization, 2011). Individuals with SSI experience pain, impairment, inadequate healing that increases the risk of hernias and wound collapse, prolonged healing periods, and psychological difficulties that result in increased resource utilization (Badia et al., 2017)(Cassini et al., 2016). Even after considering patient and operation risk factors, patients in low- and middle-income countries (LMICs) are disproportionately impacted by greater incidence of SSI as compared to those in high-income countries (Bhangu et al., 2018).

SSI Prevalence

Mortality within 30 days of surgery is the third largest contributor to global deaths (Nepogodiev et al., 2019). Surgical Site Infection (SSI) is linked to 38% of deaths in patients with SSI (Astagneau et al., 2001). The incidence rate of SSIs is significantly higher in low- and middle-income countries (LMIC) than it is in Western Europe’s comparatively high-income countries (HICs) (Rosenthal et al., 2013)(Bowley et al., 2018) and here the majority of the hospital care cost is borne by the patient (Mills, 2014). Hospital-acquired infections (HAIs) that are preventable by recognized methods include surgical site infections (SSIs) in low- and middle-income countries (LMICs). In high-income nations with efficient operations, SSI rates are falling, averaging between 1-4 percent (Gaynes et al., 2001). This reduction in SSI rates is not reflected in LMICs. SSI rates in LMICs range from 8 to 30% (Biccard et al., 2018).

Different rates of SSI post-cesarean section were reported in many countries; 16.2% in Nigeria (Morhason-Bello et al., 2009), 10.9% in Tanzania (Mpogoro et al., 2014), 19% in Kenya (Koigi-Kamau et al., 2005), and 9.7% in Vietnam (Viet Hung et al., 2016). Also, SSI complicated 14.4% of CSs in Jordan (Abdel Jalil et al., 2017), 6.2% in Turkey (Çınar et al., 2016), 4.5% in Saudi Arabia (Habib, 2002),  10.9% in Rwanda (Mukagendaneza et al., 2019), 12.6% in Nepal (Shrestha et al., 2014), 11% in Ethiopia (Wodajo et al., 2017) and 24.3% in Pakistan (Jabbar et al., 2016) graphical representation of LMICs showed in figure 1. However lower rates were reported in Israel at 3.7% (Salim et al., 2012) and in China at 3.34% (Cheng et al., 2007). Meanwhile, in another study, this rate was found in 48.2% of cesarean deliveries (CDs) at a referral center in Tanzania (De Nardo et al., 2016). In LMICs, Pakistan is the most affected country of SSI. There are many contributing factors, no proper sterilization of instruments, the CSSD department of a hospital not working properly, use of reusable linen surgical gowns, lack of knowledge about surgical attires, and no infection prevention training program.

Figure:1 Incidence of Surgical site infection in different countries

SSI Risk Factors:

A patient’s pre-existing medical conditions, malnutrition, obesity, low serum albumin, age, smoking, and immunosuppression (diabetes mellitus, radiation) are significant patient-related variables that raise the likelihood of a secondary source infection (Ansari et al., 2019). Contamination during surgery, emergency surgery, prolonged procedures, poor sterilization, careless handling of tools, and insufficient antiseptic surgical site preparation are some of the issues associated with surgery (Isaacson et al., 2020). Many traumas, hemodynamic instability, shock, large blood transfusions during the surgery, and postoperative hypoxia, hypothermia, and hyperglycaemia are physiological factors that enhance the risk of SSI (Ansari et al., 2019). Other independent predictors of SSI include abdominal surgeries, contaminated procedures, and three or more diagnoses upon hospital discharge (Emil et al., 2015). Treatment costs and hospital stays are increased when SSI is not well managed and is not recognized promptly. Patients with SSI are more likely to die than those without SSI (Khan et al., 2020).

Role of Medical Devices in SSI

In the operating room (OR), surgical site infections (SSI) are an ongoing source of concern. Patients who have skin incisions made for surgical procedures face the risk of getting serious or even deadly skin infections. Using disposable medical equipment can greatly lower the rate of surgical site infections. Let’s examine SSIs in detail and discuss how single-use medical equipment might help prevent them. Choosing medical equipment for surgery that is disposable or reusable presents a challenge for healthcare institutions. The variation between the two kinds of devices is taken into account by leading hospitals and medical centre facilitators when deciding which kind is best for patients and facility requirements: Disposable medical equipment is designed for single use, whereas reusable equipment is intended to be used again. If you decide to choose reusable medical equipment instead of single-use ones for surgical procedures, you must consider reprocessing costs. Reprocessing medical devices for future use has long been considered a best practice. However, as healthcare costs rise and concerns about cross-contamination and patient safety related to surgical site infections grow, leading surgery centres are shifting to disposable medical devices as a more dependable, affordable option that lowers operational costs and surgical site infections (Spagnolo et al., 2013).

Considering the level of infection control required to ensure the device’s safety is a crucial step in deciding between a disposable and reusable device. Based on these specifications, medical devices may be categorized into three groups. Catheters and surgical equipment are among the “critical” objects in the first of the three categories; they need to be sterile before they may penetrate sterile tissue. Devices in this category have the highest potential to spread serious or fatal illnesses when they are more contaminated than is approved (Arias, 2011). “Semi-critical” items, which are not sufficiently decontaminated as needed, fall into the second group and are likewise capable of spreading infection. Semi-critical devices, which include some endoscopes, laryngoscope blades, and equipment used in respiratory therapy and anesthesia, do not necessarily need to be sterile; however, to be used safely, they must at least be thoroughly cleaned and disinfected with a high-level disinfectant (HLD) in between uses (Conrardy et al., 2010). And the third category, “non-critical” items, are least likely to transmit disease, their infection control requirements are the least stringent. Items in this category, such as bedpans, blood pressure cuffs, stethoscopes, and pulse oximetry sensors, are intended to touch intact skin only and should never come into contact with mucous membranes or enter the body during routine use (Tieszen & Gruenberg, 1992).

Preventive strategies for SSI

• According to the Association of PeriOperative Registered Nurses (AORN) guidelines microbial contamination of the surgical site can be decreased when perioperative nurses use an authorized skin antiseptic and aseptic technique (AORN 2014).
• In Pakistan, perioperative nurses used scrubs-based povidone-iodine (PI) to disinfect the skin. This surgical preparation was unable to make SSI alleviation.
• A randomized controlled experiment comparing povidone-iodine with chlorhexidine gluconate (CHG) was carried out by Kunkel et al. The study’s findings showed that the incidence of positive cultures with povidone-iodine was seven times higher in the povidone-iodine group than in the CHG group (Kunkle et al., 2015).
• The use of chlorhexidine gluconate combined with alcohol-based skin preparation agents is highly recommended for its efficacy in reducing microbial presence on the skin (Seidelman et al., 2023).
• Maintaining normothermia during surgery further contributes to infection control, as does proper sterilization and disinfection of the surgical environment.
• Adhering to the Association of Surgical Technologists (AST) Guidelines for surgical attire and drapes in the operating theatre is essential for minimizing contamination and reduction of SSI.
• Implementing negative pressure wound therapy has also been shown to reduce the rate of SSIs, offering a proactive approach to wound management and infection prevention (Seidelman et al., 2023).

Conclusion

Surgical site infections (SSIs) are a significant global burden, particularly in low- and middle-income countries (LMICs). Patient risk factors include pre-existing medical conditions, malnutrition, and immunosuppression. Surgical factors like contamination and poor sterilization also increase SSI risk. Preventive strategies include using chlorhexidine gluconate, maintaining normothermia, and proper sterilization. Implementing negative pressure wound therapy and disposable medical equipment can further reduce SSI rates.

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