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

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Christos Anthoulakis' Quick Files

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Arterial stiffness in normotensive versus preeclamptic pregnancies

Arterial stiffness (AS) is a concept used to describe the rigidity of arterial walls. Large epidemiological studies have clearly demonstrated that AS is an independent predictor of cardiovascular morbidity and mortality in both low- and high-risk non-pregnant populations. Augmentation index (AIx) and pulse wave velocity (PWV) are well-studied diagnostic tools that are used to assess AS. The AIx is a composite measure of systemic AS derived from the ascending aortic pressure waveform. However, the gold standard of AS measurements is PWV. PWV is considered as a direct marker of AS, whereas AIx is considered as an indirect marker of AS and a direct measure of wave reflection. Preeclampsia (PE), a form of pregnancy-induced hypertension, is one of the leading causes of maternal and perinatal morbidity and mortality. Approximately 5% of pregnancies worldwide are complicated by PE. Women who develop PE are also at increased long-term risk of cardiovascular disease (CVD) and stroke in the subsequent decades. Furthermore, studies have suggested that maternal predisposition to CVD, manifested as increased PWV and blood pressure (BP), is a pre-pregnancy risk factor for PE. Evidence is accumulating that AS measurements can identify women who will later develop PE. Previous studies have reported increased AS measurements, both at the time of and prior to the onset of the clinical diagnosis of PE. These suggest that AS measurements may play a role in the prediction of PE, with AS by itself being an intrinsic part of the increased risk of future cardiovascular complications seen in women with a history of PE. Several non-invasive methods have been developed to evaluate AS. In view of simplicity, reliability and reproducibility, there is an increasing interest in oscillometric AS measurements in pregnancies complicated by PE. The objective of this study was to investigate whether oscillometric AS measurements, using 24-h non-invasive ambulatory blood pressure (BP) monitoring, are different in pregnant women with and without PE.This was a prospective case-control study in singleton pregnancies that had been diagnosed with PE (n = 46) versus normotensive controls (n = 46) between 2014 and 2019. In the case group, pregnancies complicated by PE were classified as either early-onset (< 34 weeks of gestation) or late-onset (≥ 34 weeks of gestation) PE and subgroup analysis was performed.The main outcomes of the study were pulse wave velocity (PWV), augmentation index (Alx), and Alx at a heart rate of 75 beats per minute (Alx-75). The aforementioned were measured using a brachial cuff-based automatic oscillometric device (Mobile O Graph 24h PWA). Carotid intima-media thickness (cIMT) was subsequently measured.In pregnancies complicated by PE, in comparison with normotensive pregnancies, there were significant differences in mode of conception (P = 0.016), history of previous cesarean section (P = 0.045), gestational age at delivery (P ˂0.001), mode of delivery (P <0.001), birth weight (P ˂0.001), systolic BP (P ˂0.001), diastolic BP (P ˂0.001), PWV (P ˂0.001), Alx-75 (P ˂0.001), and cIMT (P <0.001). In pregnancies complicated by early-onset PE, in comparison with pregnancies complicated by late-onset PE, there were significant differences in maternal age (P = 0.015), weight (P = 0.009), body mass index (P = 0.049), racial origin (P = 0.044), mode of conception (P = 0.02), gestational age at examination (P ˂0.001), gestational age at delivery (P ˂0.001), birth weight (P ˂0.001), systolic BP (P = 0.014), PWV (P = 0.006), Alx-75 (P = 0.009), and cIMT (P <0.001). There was no significant difference in Alx in either of the analyses.Conclusively, in comparison with normotensive pregnancies, PWV, Alx-75 and cIMT are higher in pregnancies complicated by PE. Oscillometric AS measurements before the onset of PE are required to determine if PWV and Alx-75 are useful in predicting the onset of PE.Η αρτηριακή σκληρία (ΑΣ) είναι μια έννοια που χρησιμοποιείται για να περιγράψει την ανελαστικότητα των αρτηριακών τοιχωμάτων. Μεγάλες επιδημιολογικές μελέτες δείχνουν ότι η ΑΣ αποτελεί έναν ανεξάρτητο προγνωστικό παράγοντα καρδιαγγειακής νοσηρότητας και θνησιμότητας τόσο σε χαμηλού όσο και σε υψηλού κινδύνου μη έγκυες γυναίκες. Ο δείκτης ενίσχυσης (Alx) και η ταχύτητα ροής του κύματος σφυγμού (PWV) είναι σε βάθος μελετημένα διαγνωστικά εργαλεία που χρησιμοποιούνται για την αξιολόγηση της ΑΣ. Ο Alx αποτελεί μια σύνθετη μέτρηση της κεντρικής ΑΣ προερχόμενος από την ανερχόμενη κυματομορφή της αορτικής πίεσης. Παρόλα αυτά, το “gold standard” των μετρήσεων της ΑΣ είναι η PWV. H PWV θεωρείται άμεσος δείκτης της ΑΣ, ενώ ο Alx θεωρείται έμμεσος δείκτης της ΑΣ και άμεσος δείκτης της αντανάκλασης του κύματος σφυγμού.Η προεκλαμψία (ΠΕ), μια μορφή υπερτασικής διαταραχής της κύησης, είναι μια από τις κύριες αιτίες μητρικής νοσηρότητας και θνησιμότητας. Περίπου 5% των κυήσεων παγκοσμίως επιπλέκονται από ΠΕ. Επίσης, οι κυήσεις που αναπτύσσουν ΠΕ εμφανίζουν μακροπρόθεσμα αυξημένο κίνδυνο καρδιαγγειακής νόσου και αγγειακού εγκεφαλικού επεισοδίου στις ερχόμενες δεκαετίες. Επιπροσθέτως, οι μελέτες υποστηρίζουν ότι η μητρική προδιάθεση για καρδιαγγειακή νόσο, η οποία εκδηλώνεται ως αυξημένη PWV και αρτηριακή πίεση πριν την κύηση, αποτελεί παράγοντα κινδύνου για εμφάνιση ΠΕ.Η βιβλιογραφία συγκλίνει στην παραδοχή ότι οι μετρήσεις της ΑΣ μπορούν να αναγνωρίσουν τις γυναίκες που αργότερα θα εμφανίσουν ΠΕ. Προηγούμενες μελέτες αναφέρουν αυξημένες μετρήσεις ΑΣ, τόσο κατά τη διάγνωση όσο και πριν από την εμφάνιση κλινικά εμφανούς νόσου. Τα ανωτέρω υποδεικνύουν ότι οι μετρήσεις της ΑΣ μπορεί να διαδραματίζουν κάποιο ρόλο στην πρόβλεψη της ΠΕ, με τις μετρήσεις ΑΣ να αποτελούν ένα αναπόσπαστο κομμάτι του αυξημένου κινδύνου μελλοντικής καρδιαγγειακής νόσου που παρατηρείται σε γυναίκες με ιστορικό ΠΕ.Πλειάδα μη επεμβατικών μεθόδων έχει αναπτυχτεί για την αξιολόγηση της ΑΣ. Λόγω της απλότητας, της αξιοπιστίας και της αναπαραγωγιμότητας, υπάρχει αυξανόμενο ενδιαφέρον για τις μετρήσεις ΑΣ με την ταλαντωσιμετρική μέθοδο σε κυήσεις που εμφανίζουν ΠΕ. Ο σκοπός της μελέτης αυτής ήταν να διερευνήσει εάν οι μετρήσεις ΑΣ με την ταλαντωσιμετρική μέθοδο, με τη χρήση 24ωρης περιπατητικής ή συνεχούς καταγραφής της αρτηριακής πίεσης, είναι σημαντικά διαφορετικές σε έγκυες με και χωρίς ΠΕ.Η παρούσα μελέτη ήταν προοπτική τύπου ασθενών-μαρτύρων σε μονήρεις κυήσεις που διαγνώστηκαν με ΠΕ (n = 46) έναντι νορμοτασικών κυήσεων (n = 46) μεταξύ 2014 και 2019. Στην ομάδα των ασθενών, οι κυήσεις που εμφάνισαν ΠΕ υποδιαιρέθηκαν στις πρώιμης-έναρξης ΠΕ (<34 εβδομάδες κύησης) και όψιμης-έναρξης ΠΕ (≥34 εβδομάδες κύησης) και διενεργήθηκε ανάλυση υποομάδων.Οι κύριες μετρούμενες παράμετροι ήταν η PWV, ο Alx, και ο Alx σταθμισμένος για καρδιακή συχνότητα 75 σφύξεις το λεπτό. Τα ανωτέρω μετρήθηκαν με τη χρήση αυτοματοποιημένης ταλαντωσιμετρικής συσκευής (Mobile O Graph 24h PWA), η οποία βασίζεται στην περιπατητική ή συνεχή καταγραφή της αρτηριακής πίεσης. Επιπροσθέτως μετρήθηκε το cIMT (carotid intima-media thickness).Σε κυήσεις που εμφάνισαν ΠΕ, σε αντιδιαστολή με νορμοτασικές κυήσεις, υπήρχαν σημαντικές διαφορές στον τρόπο της σύλληψης (P = 0,016), το ιστορικό προηγηθείσας καισαρικής τομής (P = 0,045), την ηλικία κύησης κατά τον τοκετό (P ˂0,001), τον τρόπο πραγμάτωσης του τοκετού (P ˂0,001), το βάρος γέννησης (P ˂0,001), τη συστολική αρτηριακή πίεση (P ˂0,001), τη διαστολική αρτηριακή πίεση (P ˂0,001), την PWV (P ˂0,001), τον Alx-75 (P ˂0,001), και το cIMT (P <0,001). Σε κυήσεις που εμφάνισαν πρώιμης-έναρξης ΠΕ, σε αντιδιαστολή με όψιμης-έναρξης ΠΕ, υπήρχαν σημαντικές διαφορές στη μητρική ηλικία (P = 0,015), βάρος (P = 0,009), δείκτη μάζας σώματος (P = 0,049), την καταγωγή (P = 0,044), στον τρόπο της σύλληψης (P = 0,02), την ηλικία κύησης κατά την εξέταση (P ˂0,001), την ηλικία κύησης κατά τον τοκετό (P ˂0,001), το βάρος γέννησης (P ˂0,001), τη συστολική αρτηριακή πίεση (P = 0,014), την PWV (P = 0,006), τον Alx-75 (P = 0,009), και το cIMT (P <0,001). Δεν υπήρχε σημαντική διαφορά στον Alx σε ούτε στη βασική ανάλυση ούτε στην ανάλυση υποομάδων.Συμπερασματικά, σε αντιδιαστολή με νορμοτασικές κυήσεις, η PWV, ο Alx-75 και το cIMT είναι αυξημένοι σε κυήσεις που εμφανίζουν ΠΕ. Οι μετρήσεις των δεικτών της ΑΣ με τη χρήση ταλαντωσιμετρικής μεθόδου πριν την εμφάνιση ΠΕ είναι απαραίτητες για να προσδιοριστεί εάν η PWV, ο Alx-75 και το cIMT είναι χρήσιμοι στην πρόβλεψη της ΠΕ

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

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

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

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

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