Prevalence of orthopaedic surgical site infection in Egypt

Introduction

Surgical site infection (SSI) remains a significant and challenging complication following orthopedic surgeries, impacting patient outcomes and healthcare systems globally [1] Anderson DJ, Podgorny K, Berríos-Torres SI, et al (2014) Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 Update. Infect Control Hosp Epidemiol 35:605–627. https://doi.org/10.1086/676022. These infections, which occur at the site of surgery within 30 days postoperatively or within a year if an implant is placed, pose a serious threat due to the intricate nature of orthopedic procedures and the complex environments in which they are performed [2] Mangram AJ, Horan TC, Pearson ML, et al (1999) Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control 27:97–132; quiz 133–4; discussion 96. Orthopedic SSIs can lead to extended hospital stays, increased medical costs, additional surgical interventions, and, most critically, substantial morbidity and mortality among patients [3] de Lissovoy G, Fraeman K, Hutchins V, et al (2009) Surgical site infection: Incidence and impact on hospital utilization and treatment costs. Am J Infect Control 37:387–397. https://doi.org/10.1016/j.ajic.2008.12.010.

The prevalence of SSIs in orthopedic surgeries varies widely, influenced by factors such as the type of surgery, patient comorbidities, surgical techniques, and adherence to infection control protocols [4] Owens CD, Stoessel K (2008) Surgical site infections: epidemiology, microbiology and prevention. Journal of Hospital Infection 70:3–10. https://doi.org/10.1016/S0195-6701(08)60017-1. Common pathogens responsible for these infections include Staphylococcus aureus, including methicillin-resistant strains (MRSA), coagulase-negative staphylococci, and Gram-negative bacilli [5] Anderson PA, Savage JW, Vaccaro AR, et al (2017) Prevention of Surgical Site Infection in Spine Surgery. Neurosurgery 80:S114–S123. https://doi.org/10.1093/neuros/nyw066. The advent of antibiotic-resistant organisms further complicates the management and prevention of SSIs in orthopedic settings [6] Hawn MT, Vick CC, Richman J, et al (2011) Surgical Site Infection Prevention. Ann Surg 254:494–501. https://doi.org/10.1097/SLA.0b013e31822c6929.

Preventive measures are multifaceted, involving preoperative, intraoperative, and postoperative strategies [7] Kirkland KB, Briggs JP, Trivette SL, et al (1999) The Impact of Surgical-Site Infections in the 1990s: Attributable Mortality, Excess Length of Hospitalization, And Extra Costs. Infect Control Hosp Epidemiol 20:725–730. https://doi.org/10.1086/501572. Preoperative measures include optimizing patient health, controlling blood glucose levels, and appropriate antibiotic prophylaxis [8] Lee JT, Murrill CA (2009) Strategies for reducing the risk of surgical site infection: a clinical update. Contemporary Surgery 65:242–248. Intraoperatively, meticulous surgical technique, proper sterilization of instruments, and maintaining normothermia are crucial [4] Owens CD, Stoessel K (2008) Surgical site infections: epidemiology, microbiology and prevention. Journal of Hospital Infection 70:3–10. https://doi.org/10.1016/S0195-6701(08)60017-1. Postoperative care involves wound management, timely removal of drains and catheters, and vigilant monitoring for early signs of infection [9] Bratzler DW, Dellinger EP, Olsen KM, et al (2013) Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery. Surg Infect (Larchmt) 14:73–156. https://doi.org/10.1089/sur.2013.9999.

Despite advances in surgical techniques and infection control practices, the incidence of SSIs in orthopedic surgeries remains a pressing concern. Ongoing research and the development of innovative strategies are essential to reduce the burden of these infections and improve patient outcomes in orthopedic care.

Methods

The procedural framework of this investigation adhered to the methodology outlined in the Cochrane Handbook for Systematic Reviews and Meta-analysis [10] Higgins JPT, Thomas J, Chandler J, et al (2019) Cochrane handbook for systematic reviews of interventions, sixth. We followed the PRISMA statement guidelines in reporting this meta-analysis [11] Page MJ, McKenzie JE, Bossuyt PM, et al (2021) Updating guidance for reporting systematic reviews: development of the PRISMA 2020 statement. J Clin Epidemiol 134:103–112. https://doi.org/10.1016/j.jclinepi.2021.02.003.

1. Literature search

We conducted a methodical search across the subsequent databases: PubMed, Scopus, Web of Science (WOS), and Embase, aiming to retrieve relevant published studies from their inception until June 2024. We used keywords to build our search strategy including (“Surgical Wound Infection”[Mesh] OR “Surgical Site Infection” OR “SSI” OR “Postoperative Infection”) AND (“Prevalence” OR “Epidemiology” OR “Incidence” OR “Rate”) AND (“Egypt” OR “Egyptian”). All duplicates were removed by Endnote software.

Rayyan software [12] Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A (2016) Rayyan—a web and mobile app for systematic reviews. Syst Rev 5:210. https://doi.org/10.1186/s13643-016-0384-4 was utilized during the selection process, with two reviewers independently and blindly assessing the retrieved references in a two-stage procedure. First, they screened the titles and abstracts of all extracted articles. In the second phase, they conducted a thorough full-text screening of all eligible abstracts. Any discrepancies were resolved with the assistance of a third reviewer.

2. Selection and Eligibility criteria

In selecting relevant studies, we followed a specific set of criteria. This investigation focused on patients undergoing any type of orthopedic surgery without interventions or comparators, with the primary outcome being the incidence of surgical site infections (SSIs). We excluded non-English studies, case reports, animal studies, reviews, editorials, studies with only an abstract or unavailable full text, or overlapping data.

3. Data Extraction

Data from eligible studies was gathered on a standardized sheet for data extraction form by two independent reviewers. Then a cross-verification was conducted, and any discrepancies were addressed through discussion. The uniform data extraction sheet encompasses two domains, from which details related to the included studies are derived, first domain was: characteristics of included studies such as (study ID, Study design, Country, Number of centers, inclusion criteria, number of patients, follow-up duration and conclusion). The second domain included the outcomes that we highlighted on them previously.

4. Quality assessment

Two authors independently evaluated the Risk of bias using the Joanna Briggs Institute (JBI) critical appraisal tools [34] Iskandar K (2023) Surgical Site Infection Management in Developing Countries. In: Handbook of Medical and Health Sciences in Developing Countries. Springer International Publishing, Cham, pp 1–26. The suitable checklist was selected based on the observational study type. Each checklist included various questions that could be answered with “yes,” “unclear,” “no,” or “not applicable.” Discrepancies were resolved through consensus. Studies were categorized as having a low, medium, or high risk of bias according to the relevant questions. [13] Barker TH, Stone JC, Sears K, et al (2023) Revising the JBI quantitative critical appraisal tools to improve their applicability: an overview of methods and the development process. JBI Evid Synth 21:478–493. https://doi.org/10.11124/JBIES-22-00125

5. Statistical analysis

For comprehensive analysis of extracted data, we used OpenMeta[Analyst] software tool for analysis and construction of forest blots; For dichotomous outcomes, we pooled them as Risk ratio (RR) and their corresponding 95% confidence interval (CI) using the Mantel-Haenszel method, we also performed sensitivity analysis to solve the heterogeneity.

Additionally, to assess statistical heterogeneity among the included studies, a visual inspection of the forest plots was conducted. The Chi-square test (Cochrane Q test) and the Higgins and Thompson I² statistic were also used to quantify heterogeneity, with the formula I² = ((Q - df) / Q) x 100%. If the I² value exceeded 50% and the Chi-square test’s p-value was less than 0.1, significant statistical heterogeneity was considered present between the studies. In such cases, DerSimonian and Laird random effects models were applied to address the heterogeneity effectively.

On the other hand, heterogeneity would be fluctuated as low, moderate, and high whether I2 valued as < 25%, from 25-75%, or > 75%, respectively [14] Higgins JPT (2003) Measuring inconsistency in meta-analyses. BMJ 327:557–560. https://doi.org/10.1136/bmj.327.7414.557.

Results

1. Search Results and Study Selection

680 publications were found by scanning the various electronic databases (PubMed, Web of Science, Scopus, and Ovid). 180 articles were discovered to be duplicates and deleted. Through the application of the above-described inclusion and exclusion criteria, 677 studies were deemed irrelevant and subsequently eliminated throughout the screening process. Ultimately, it was determined that three studies [15], Afifi IK, Baghagho EA (2010) Three months study of orthopaedic surgical site infections in an Egyptian University hospital. Int J Infect Control 6:. https://doi.org/10.3396/ijic.v6i1.002.10[16], Khaleid M. Abdel-Haleim, Zeinab Abdel-Khalek Ibraheim, Eman M. El-Tahlawy (2010) Surgical Site Infections and Associated Risk Factors in Egyptian Orthopedic Patients. Journal of American Science 6:272–280[17] Kotb N, Mahammad Z, El kadey H, Abd El-mohsen S (2019) Prevalence and risk factors leading to orthopedic wound infection at Assiut Hospital University. Assiut Scientific Nursing Journal 7:111–120. https://doi.org/10.21608/asnj.2019.56974 qualified and were included in the analysis. (Figure 1)

2. Characteristics of Included Studies

All the included studies were carried out in Egypt including one prospective analytical study, one single institution study, and one cross-sectional study (Table 1). The follow up duration was different among these studies ranging from three to nine months.

3. Quality assessment of the included studies

Two studies were classified as having medium concerns regarding the methodological quality and one study, Kotb et al 2019, demonstrated a weak adherence to methodological guidelines and high risk of bias, which decreased the validity of its findings. (Table 2 and 3)

4. Prevalence of surgical site infection in orthopedic patients

The analysis of SSI revealed that its incidence is statistically significant (P value < 0.05) with a risk ratio (RR) = 0.224 and 95% confidence interval (CI) [0.125; - 0.323. with significant heterogeneity I^2=81.09. (Figure 2)

5. Sensitivity analysis on prevalence of surgical site infection in orthopedic patients

After removal of the study Afifi 2010 [15] Afifi IK, Baghagho EA (2010) Three months study of orthopaedic surgical site infections in an Egyptian University hospital. Int J Infect Control 6:. https://doi.org/10.3396/ijic.v6i1.002.10 the heterogeneity was resolved I^2 = 0%. (Figure 3)

Discussion

Surgical site infections (SSI) are the most common complications in surgical patients and the second most common complications in orthopedic patients leading to prolonged hospital stay, readmissions to the hospital, and increased morbidity and mortality [18], van Kasteren MEE, Mannien J, Kullberg B-J, et al (2005) Quality improvement of surgical prophylaxis in Dutch hospitals: evaluation of a multi-site intervention by time series analysis. Journal of Antimicrobial Chemotherapy 56:1094–1102. https://doi.org/10.1093/jac/dki374[19] Jodra VM, Soler LS de los T, Pérez CD-A, et al (2006) Excess Length of Stay Attributable to Surgical Site Infection Following Hip Replacement: A Nested Case-Control Study. Infect Control Hosp Epidemiol 27:1299–1303. https://doi.org/10.1086/509828. One of the most common challenges that orthopedic surgeons face is the use of implants for open reduction and internal fixation which are foreign objects to the body increasing the risk of SSI. [20] Vishwajith Y, Anuradha.K, Venkatesha (2014) Evaluation of aerobic bacterial isolates and its drug susceptibility pattern in orthopedic infections. Journal of medical science and clinical research 2:1256–1262

The aim of this analysis is to estimate the incidence of SSI in orthopedic surgeries in Egyptian hospitals. The orthopedic procedures in the included studies were mainly internal fixation of fractures and arthroplasty.

Our findings estimated the incidence of SSI to range from 12.5% to 32.3%, with statistically significant results (RR = 0.224, 95% CI [0.125 to 0.323], p < 0.05].

In 2002, SSI was the second leading cause of healthcare-associated infections (HAI) in both the USA and Europe. In the USA, there were nearly 270,000 episodes per year, accounting for 20% of HAIs, while in Europe, there were approximately 900,000 episodes annually, representing 19.6% of HAIs [21] Benedetta Allegranzi (2014) The burden of surgical site infections worldwide. A recent meta-analysis with a total of 43 studies from 29 countries no including Egypt aimed to estimate the global incidence of SSI [22] Mengistu DA, Alemu A, Abdukadir AA, et al (2023) Global Incidence of Surgical Site Infection Among Patients: Systematic Review and Meta-Analysis. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 60:004695802311625. https://doi.org/10.1177/00469580231162549. The study found a worldwide SSI incidence rate of 2.5%, which is notably lower than the 5.6% reported by Allegranzi et al [23] Allegranzi B, Nejad SB, Combescure C, et al (2011) Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis. The Lancet 377:228–241. https://doi.org/10.1016/S0140-6736(10)61458-4. Moreover, according to Mengistu et al [22] Mengistu DA, Alemu A, Abdukadir AA, et al (2023) Global Incidence of Surgical Site Infection Among Patients: Systematic Review and Meta-Analysis. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 60:004695802311625. https://doi.org/10.1177/00469580231162549, the highest incidence of SSI worldwide was found in studies conducted in Africa, accounting for 7.2% [22] Mengistu DA, Alemu A, Abdukadir AA, et al (2023) Global Incidence of Surgical Site Infection Among Patients: Systematic Review and Meta-Analysis. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 60:004695802311625. https://doi.org/10.1177/00469580231162549. This finding aligns closely with Allegranzi et al [23] Allegranzi B, Nejad SB, Combescure C, et al (2011) Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis. The Lancet 377:228–241. https://doi.org/10.1016/S0140-6736(10)61458-4, which reported a pooled SSI incidence of 5.6% among patients in developing countries. Also, Ngaroua et al, which aimed to estimate the incidence of SSI in sub-Saharan Africa reported a pooled SSI incidence of 14.8% [24] Ngaroua, Ngah JE, Bénet T, Djibrilla Y (2016) Incidence des infections du site opératoire en Afrique sub-saharienne: revue systématique et méta-analyse. Pan African Medical Journal 24:. https://doi.org/10.11604/pamj.2016.24.171.9754. All these outcomes are lower than those reported in Egypt ranging from 12.5% to 32.3%.

Multiple risk factors could be attributed to this high-risk SSI. Male gender may be associated with high risk of SSI as proven by Al-Qurayshi et al and Utsumi et al [25], Al-Qurayshi Z, Baker SM, Garstka M, et al (2018) Post-Operative Infections: Trends in Distribution, Risk Factors, and Clinical and Economic Burdens. Surg Infect (Larchmt) 19:717–722. https://doi.org/10.1089/sur.2018.127[26] Utsumi M, Shimizu J, Miyamoto A, et al (2010) Age as an independent risk factor for surgical site infections in a large gastrointestinal surgery cohort in Japan. Journal of Hospital Infection 75:183–187. https://doi.org/10.1016/j.jhin.2010.01.021 this could be related to the fact that hormones may play a role in defining proper immune response where females have eminent cell-mediated immune responses compared with males owing to their low testosterone levels [27] Langelotz C, Mueller-Rau C, Terziyski S, et al (2014) Gender-Specific Differences in Surgical Site Infections: An Analysis of 438,050 Surgical Procedures from the German National Nosocomial Infections Surveillance System. Visc Med 30:114–117. https://doi.org/10.1159/000362100, also older patients between 17 and 65 years demonstrated higher risk for SSI, while patients aged 65 and above showed low risk of SSI by 1.2% for every year based on Kaye et al [28] Kaye KS, Schmit K, Pieper C, et al (2005) The Effect of Increasing Age on the Risk of Surgical Site Infection. J Infect Dis 191:1056–1062. https://doi.org/10.1086/428626 which is inconsistent with Hegazy et al and Al-Mulhim et al that reported higher risk of SSI in younger patients [29], Hegazy E (2021) Assessment of Surgical Site Infections; bacterial isolates, prevalence and their antibiogram pattern at Cairo University Hospitals, Cairo, Egypt. Egypt J Med Microbiol 30:75–84. https://doi.org/10.21608/ejmm.2021.197465[30] Al-Mulhim FA, Baragbah MA, Sadat-Ali M, et al (2014) Prevalence of Surgical Site Infection in Orthopedic Surgery: A 5-year Analysis. Int Surg 99:264–268. https://doi.org/10.9738/INTSURG-D-13-00251.1, but it could be due to the majority of patients in Al-Mulhim et al were reported to have traumatic injury and it has been shown that preoperative injury to soft tissues is a major risk factor for SSI. [30], Al-Mulhim FA, Baragbah MA, Sadat-Ali M, et al (2014) Prevalence of Surgical Site Infection in Orthopedic Surgery: A 5-year Analysis. Int Surg 99:264–268. https://doi.org/10.9738/INTSURG-D-13-00251.1[31] Bachoura A, Guitton TG, Smith MR, et al (2011) Infirmity and Injury Complexity are Risk Factors for Surgical-site Infection after Operative Fracture Care. Clin Orthop Relat Res 469:2621–2630. https://doi.org/10.1007/s11999-010-1737-2

Additionally, smoking significantly increases the risk of SSI as it is known for its negative effect on immunity causing impaired wound healing, wound dehiscence, and incisional hernia [32] Bodnar JA, Morgan WT, Murphy PA, Ogden MW (2012) Mainstream smoke chemistry analysis of samples from the 2009 US cigarette market. Regulatory Toxicology and Pharmacology 64:35–42. https://doi.org/10.1016/j.yrtph.2012.05.011. Sheet et al. highlights a growing concern about smoking in developing nations, where almost 80% of the world’s 1.1 billion smokers live. Furthermore, additional risk factors such as obesity, duration of surgery, pre-existing infections, blood transfusions, low serum albumin levels, and inadequate sterilization practices may contribute to the high rate of SSIs in Egypt and other developing countries. [33], Cheadle WG (2006) Risk Factors for Surgical Site Infection. Surg Infect (Larchmt) 7:s7–s11. https://doi.org/10.1089/sur.2006.7.s1-7[34] Iskandar K (2023) Surgical Site Infection Management in Developing Countries. In: Handbook of Medical and Health Sciences in Developing Countries. Springer International Publishing, Cham, pp 1–26

This is the first meta-analysis conducted to evaluate the prevalence of orthopedic SSI in Egyptian hospitals. A comprehensive search strategy was formulated and used to search different electronic databases to retrieve all relevant studies. This meta-analysis strictly followed the Cochrane Handbook guidelines, including only RCTs and having at least two authors involved in each step. This meticulous methodology enhanced the reliability of our findings and provided important insights into the prevalence of orthopedic SSI in Egypt. Nonetheless, our study encountered several challenges. The limited number of included studies and the small sample sizes hindered our ability to gather comprehensive data on the prevalence of SSIs in Egypt. Moreover, the three studies we included only covered patients from three hospitals in Egypt: Assiut, Tanta, and Cairo. There are several gaps in the surveillance of SSI including the lack of surveillance methodologies post-discharge (patients encountered some difficulty to assess their own wounds for infection), no data from many hospitals, and the absence or limited written guidelines on proper perioperative antibiotic policies.

A multicenter surveillance study, on many homogeneous Orthopedic cases with larger sample size and longer duration, is needed to allow for meaningful comparisons between different Orthopedic conditions and hospitals.