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 health-care–associated infections, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery worldwide. Methods: International, prospective, multicentre cohort study of consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time windows at any participating hospital worldwide. Countries were stratified into high-, middle-, and low-HDI groups. Risk-adjustment used variables from GlobalSurg 1 and other studies. Primary outcome: 30-day SSI incidence (CDC criteria for superficial and deep incisional SSI). Bayesian multilevel logistic regression explored relationships with explanatory variables. ClinicalTrials.gov: NCT02662231. Findings: From Jan 4 to July 31, 2016, 12,539 patients from 343 hospitals in 66 countries were included: 7,339 high-HDI (58.5%), 3,918 middle-HDI (31.2%), 1,282 low-HDI (10.2%). Overall, 1,538 (12.3%) developed SSI within 30 days. SSI incidence by HDI: high 9.4% (691/7,339), middle 14.0% (549/3,918), low 23.2% (298/1,282; p<0.001). Highest SSI incidence occurred after dirty surgery in each HDI group (high 17.8%, middle 31.4%, low 39.8%). After risk adjustment, patients in low-HDI countries were at greatest risk (adjusted OR 1.60, 95% CrI 1.05–2.37; p=0.030). Among 610 SSIs with culture, 132 (21.6%) were resistant to the prophylactic antibiotic used, varying by HDI (high 16.6%, middle 19.8%, low 35.9%; p<0.001). Interpretation: Low-HDI countries carry a disproportionately greater SSI burden and may have higher antibiotic resistance rates. Given limited high-quality interventional evidence, especially from LMICs, urgent, pragmatic randomized trials are needed to evaluate SSI prevention strategies. Funding: DFID-MRC-Wellcome Trust Joint Global Health Trial Development Grant; NIHR Global Health Research Unit Grant.