Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Resistant Starch Tipe 3 Singkong (Manihot esculenta Crantz) Menurunkan Kadar Trigliserida Tikus Model Diabetes

Diabetes Mellitus (DM) merupakan kelainan metabolik yang ditandai dengan kondisi hiperglikemia kronis disertai gangguan karbohidrat, protein, dan lemak. DM dibagi menjadi empat tipe salah satunya yaitu DM tipe 2 yang diakibatkan oleh resistensi insulin dan disfungsi sel β pankreas. Prevalensi DM penduduk Indonesia pada usia produktif di perkotaan yaitu sebesar 4,6%, di mana lebih dari 50% disertai dengan dislipidemia karena jalur metabolisme lipid dipengaruhi oleh insulin. Peningkatan kadar trigliserida lebih dari 150 mg/dL atau yang disebut juga hipertrigliseridemia merupakan karakteristik dislipidemia yang paling dominan pada DM tipe 2. Hipertrigliseridemia ditandai dengan peningkatan Very Low Density Lipoprotein (VLDL), yang merupakan lipoprotein pengangkut trigliserida. Pada keadaan resistensi insulin, enzim Lipoprotein Lipase (LPL) dihambat sedangkan aktivitas Hormone Sensitive Lipase (HSL) di jaringan adiposa meningkat menyebabkan peningkatan Free Fatty Acid (FFA), yang merupakan substrat pembentukan trigliserida hepatik VLDL. Resistensi insulin juga menyebabkan lipogenesis terutama di liver dan otot akibat akumulasi FFA yang tidak dapat dioksidasi di mitokondria. Salah satu pilar pengelolaan DM yaitu dengan terapi diet. Beberapa penelitian telah membuktikan efek pemberian Resistant Starch (RS) terhadap diabetes dan metabolisme lipid. RS tersusun dari amilosa dan amilopektin, yang merupakan pati tahan cerna oleh enzim amilase di saluran pencernaan atas. Namun, RS dapat difermentasi oleh mikrobiota di kolon menghasilkan Short Chain Fatty Acid (SCFA) yang terdiri atas asetat, butirat, dan propionat. Singkong (Manihot esculenta Crantz) merupakan bahan makanan kaya RS dengan kadar amilosa-amilopektin sebesar 9,69% lebih banyak dibandingkan padi dan jagung. Modifikasi pati menggunakan teknik autoclaving-cooling dapat membentuk RS tipe 3 serta meningkatkan kadar amilosa-amilopektin tersebut. Penelitian ini bertujuan untuk mengetahui efek RS tipe 3 singkong dalam menurunkan kadar trigliserida pada tikus model diabetes. Desain penelitian yang digunakan yaitu true experimental post-test only control group design. Jumlah sampel penelitian yaitu 16 ekor tikus wistar jantan yang dibagi menjadi 4 kelompok yaitu kelompok kontrol normal (KN), kontrol negatif K(-), Perlakuan 1 (P1), dan Perlakuan 2 (P2). Pemeriksaan karakteristik awal tikus dilakukan dengan mengukur berat badan (BB) dan kadar trigliserida. Kelompok K(-), P1, dan P2 diberi pakan High Fat Diet (HFD) kuning telur 0,01 mg/kgBB selama 4 minggu dan diikuti induksi Streptozotocin (STZ) dosis rendah 35 mg/kgBB. Pengukuran tes toleransi glukosa oral untuk memastikan telah terbentuk tikus model diabetes dilakukan tujuh hari setelah induksi STZ. Kemudian dilanjutkan dengan pemberian diet selama 4 minggu. KN diberi 30 g diet standar, K(-) 30 g diet standar, P1 20 g RS tipe 3 dan 10 g diet standar, serta P2 20 g pati singkong dan 10 g diet standar. Pengukuran kadar trigliserida dilakukan dengan metode GPO-PAP. Data tes toleransi glukosa oral dianalisis dengan uji Kruskal-wallis sedangkan kadar trigliserida sesudah perlakuan diet dianalisis dengan One Way ANOVA dilanjutkan dengan uji Post Hoc Tukey. Hasil penelitian didapatkan perbedaan kadar trigliserida yang signifikan antara kelompok perlakuan (p0,05). Pada penelitian ini RS tipe 3 dapat menurunkan kadar trigliserida tikus model diabetes. Penurunan kadar trigliserida terjadi akibat RS tipe 3 singkong dapat mengaktifkan AMPK di berbagai jaringan melalui Free Fatty Acid Receptor (FFAR) 2 dan 3. Di adiposa, AMPK menyebabkan aktivitas LPL meningkat sedangkan HSL menurun. Pada jaringan otot dan liver, AMPK menyebabkan penurunan lipogenesis dan peningkatan oksidasi Fatty Acids (FA) serta ambilan glukosa. Berdasarkan hal tersebut, maka RS tipe 3 dapat dijadikan inovasi perencanaan diet bagi pasien DM terutama yang disertai dengan hipertrigliseridemia

Surgical site infection after gastrointestinal surgery in children : an international, multicentre, prospective cohort study

Introduction Surgical site infection (SSI) is one of the most common healthcare-associated infections (HAIs). However, there is a lack of data available about SSI in children worldwide, especially from low-income and middle-income countries. This study aimed to estimate the incidence of SSI in children and associations between SSI and morbidity across human development settings. Methods A multicentre, international, prospective, validated cohort study of children aged under 16 years undergoing clean-contaminated, contaminated or dirty gastrointestinal surgery. Any hospital in the world providing paediatric surgery was eligible to contribute data between January and July 2016. The primary outcome was the incidence of SSI by 30 days. Relationships between explanatory variables and SSI were examined using multilevel logistic regression. Countries were stratified into high development, middle development and low development groups using the United Nations Human Development Index (HDI). Results Of 1159 children across 181 hospitals in 51 countries, 523 (45 center dot 1%) children were from high HDI, 397 (34 center dot 2%) from middle HDI and 239 (20 center dot 6%) from low HDI countries. The 30-day SSI rate was 6.3% (33/523) in high HDI, 12 center dot 8% (51/397) in middle HDI and 24 center dot 7% (59/239) in low HDI countries. SSI was associated with higher incidence of 30-day mortality, intervention, organ-space infection and other HAIs, with the highest rates seen in low HDI countries. Median length of stay in patients who had an SSI was longer (7.0 days), compared with 3.0 days in patients who did not have an SSI. Use of laparoscopy was associated with significantly lower SSI rates, even after accounting for HDI. Conclusion The odds of SSI in children is nearly four times greater in low HDI compared with high HDI countries. Policies to reduce SSI should be prioritised as part of the wider global agenda.Peer reviewe

Exploring the cost-effectiveness of high versus low perioperative fraction of inspired oxygen in the prevention of surgical site infections among abdominal surgery patients in three low- and middle-income countries

Background: This study assessed the potential cost-effectiveness of high (80–100%) vs low (21–35%) fraction of inspired oxygen (FiO2) at preventing surgical site infections (SSIs) after abdominal surgery in Nigeria, India, and South Africa. Methods: Decision-analytic models were constructed using best available evidence sourced from unbundled data of an ongoing pilot trial assessing the effectiveness of high FiO2, published literature, and a cost survey in Nigeria, India, and South Africa. Effectiveness was measured as percentage of SSIs at 30 days after surgery, a healthcare perspective was adopted, and costs were reported in US dollars ($). Results: High FiO2 may be cost-effective (cheaper and effective). In Nigeria, the average cost for high FiO2 was$216 compared with $222 for low FiO2 leading to a −$6 (95% confidence interval [CI]: −$13 to −$1) difference in costs. In India, the average cost for high FiO2 was $184 compared with$195 for low FiO2 leading to a −$11 (95$15 to −$6) difference in costs. In South Africa, the average cost for high FiO2 was$1164 compared with $1257 for low FiO2 leading to a −$93 (95% CI: −$132 to −$65) difference in costs. The high FiO2 arm had few SSIs, 7.33% compared with 8.38% for low FiO2, leading to a −1.05 (95% CI: −1.14 to −0.90) percentage point reduction in SSIs. Conclusion: High FiO2 could be cost-effective at preventing SSIs in the three countries but further data from large clinical trials are required to confirm this

Treating MERS-CoV during an outbreak

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p<0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p<0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication. Funding: DFID-MRC-Wellcome Trust Joint Global Health Trial Development Grant, National Institute of Health Research Global Health Research Unit Grant

Use of Telemedicine for Post-discharge Assessment of the Surgical Wound: International Cohort Study, and Systematic Review with Meta-analysis

Objective: This study aimed to determine whether remote wound reviews using telemedicine can be safely upscaled, and if standardised assessment tools are needed. Summary background data: Surgical site infection is the most common complication of surgery worldwide, and frequently occurs after hospital discharge. Evidence to support implementation of telemedicine during postoperative recovery will be an essential component of pandemic recovery. Methods: The primary outcome of this study was surgical site infection reported up to 30-days after surgery (SSI), comparing rates reported using telemedicine (telephone and/or video assessment) to those with in-person review. The first part of this study analysed primary data from an international cohort study of adult patients undergoing abdominal surgery who were discharged from hospital before 30-days after surgery. The second part combined this data with the results of a systematic review to perform a meta-analysis of all available data conducted in accordance with PRIMSA guidelines (PROSPERO:192596). Results: The cohort study included 15,358 patients from 66 countries (8069 high, 4448 middle, 1744 low income). Of these, 6907 (45.0%) were followed up using telemedicine. The SSI rate reported using telemedicine was slightly lower than with in-person follow-up (13.4% vs. 11.1%, P&lt;0.001), which persisted after risk adjustment in a mixed-effects model (adjusted odds ratio: 0.73, 95% confidence interval 0.63-0.84, P&lt;0.001). This association was consistent across sensitivity and subgroup analyses, including a propensity-score matched model. In nine eligible non-randomised studies identified, a pooled mean of 64% of patients underwent telemedicine follow-up. Upon meta-analysis, the SSI rate reported was lower with telemedicine (odds ratio: 0.67, 0.47-0.94) than in-person (reference) follow-up (I2=0.45, P=0.12), although there a high risk of bias in included studies. Conclusions: Use of telemedicine to assess the surgical wound post-discharge is feasible, but risks underreporting of SSI. Standardised tools for remote assessment of SSI must be evaluated and adopted as telemedicine is upscaled globally

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world