World Journal of Surgical Infection

: 2022  |  Volume : 1  |  Issue : 2  |  Page : 67--70

Investing in surgical site infection control toward safe surgery and universal health coverage

Justina O Seyi-Olajide1, Emmanuel Adoyi Ameh2,  
1 Department of Surgery, Lagos University Teaching Hospital, Lagos, Nigeria
2 Department of Surgery, National Hospital, Abuja, Nigeria

Correspondence Address:
Emmanuel Adoyi Ameh
Department of Surgery, National Hospital, Abuja


Surgical site infection (SSI) is a common but preventable complication after surgery and is a major cause of postoperative morbidity and mortality in low-and middle-income countries. Antimicrobial resistance (AMR) rates are also high in the setting. To scale up access to surgical care toward achieving the goals of universal health coverage, several countries in the setting have created surgical plans. These plans aim to significantly increase surgical volumes. These countries must scale up infection prevention and control programs at the same pace to avoid uncontrollable increases in SSI and AMR rates. Implementation of the safe surgery checklist needs to be scaled up to support SSI prevention and control programs.

How to cite this article:
Seyi-Olajide JO, Ameh EA. Investing in surgical site infection control toward safe surgery and universal health coverage.World J Surg Infect 2022;1:67-70

How to cite this URL:
Seyi-Olajide JO, Ameh EA. Investing in surgical site infection control toward safe surgery and universal health coverage. World J Surg Infect [serial online] 2022 [cited 2023 Jun 5 ];1:67-70
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Full Text


Surgical site infection (SSI) is among the most common preventable complication after surgery.[1] Despite this, it is a major cause of postoperative morbidity and mortality in low-and middle-income countries (LMICs). Reported rates of SSI vary widely across different world regions ranging between 4.3% and 60.4% in Africa, 6.3%–9.3% in South East Asia, 0.6%–5.5% in South America, 2%–4% in North America, and 3%–5.4% in Europe.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13] The research methods used in these studies, however, differ significantly making it difficult to compare the rates. Countries with low human development index (HDI) also have a disproportionately greater burden of SSI than countries with middle or high HDI with the possibility of higher rates of antibiotic resistance.[14] Global surgery places priority on improving health outcomes and achieving health equity for all people worldwide who are affected by surgical conditions or have a need for surgical care.[15] The current unacceptably high SSI rates especially in surgically needy regions with their attendant impact on surgical outcomes show that the goals of global surgery and global health, and universal health coverage (UHC) will not be achieved unless the problem of SSI is adequately addressed.

 Current Profile of Global Surgery

The finding that at least half of the world's population lack access to much needed healthcare, with about a million people each year, pushed into extreme poverty from out-of-pocket expenditure on health resulted in the United Nations resolution on UHC.[16] Surgical care was, however, not prioritized in the UHC at the time. The work of the Lancet Commission on Global Surgery (LCoGS) and Global Surgery Advocacy led to the World Health Assembly (WHA) resolution (Resolution 68.15) on Strengthening Emergency and Essential Surgical Care and Anesthesia as a component of UHC.[17] Country-level efforts to implement the WHA Resolution 68.15, necessitated the creation of surgical plans for the scale-up of access to surgical care. These events have led to much progress in global surgery in the last few years with global surgery now more prominent on the global health agenda. Sale up of access to surgical care implies an increase in surgical volume. Countries that have developed surgical plans are also devising mechanisms to increase their surgical volume based on the LCoGS core surgical indicator 2030 targets [Table 1]. By 2023, Nigeria plans to increase surgical volume by 100% of the baseline of 58.62/100,000, Rwanda plans to achieve 5000 surgeries/100,000 population from a baseline of 786, and Zambia 4916 surgeries/100,000 by 2021 (80% Increase) from a baseline of 1617. Tanzania's goal is that all hospitals will be able to provide recommended surgical, obstetrics, and anesthesia services for their level of care by 2025.{Table 1}

 Implications of Surgical Scale-Up for Surgical Site Infection

The true burden of SSIs in LMICs where they are prevalent is unknown. There is a lack of comprehensive and generalizable reports on the subject with most data emanating from single-institution reports. A report involving patients from over 60 countries reported SSI rates of 9.4%, 14.0%, and 23.2% in countries with high, middle, and low HDI, respectively.[14] Another report showed that SSI was the leading cause of hospital-associated infections in developing countries with a cumulative incidence of 5.6/100 surgical procedures. Rates as high as 60.4% have been reported from Africa. Most of the hospitals in these regions also lack infection prevention and control programs (IPCs). Increasing surgical volume to 5000/100,000 population is one of the core surgical indicators that have defined the targets set in all country surgical plans that have been created. Scaling up the surgical volume without simultaneously investing in the implementation of IPC programs and protocols, may result in a blowout of SSIs.

The ongoing recognition of the vital role of surgery in achieving UHC, provides a unique opportunity for (1) Development of a worldwide approach to SSI prevention and control and (2) Acceleration of advocacy and research in SSI, particularly in LMICs.

In LMICs, there appears to be a resignation to the fact that SSIs are inevitable even though they are, however, preventable. This situation needs to be reversed.

 Role of Antimicrobial Resistance

The increasing rates of antimicrobial resistance (AMR) pose a significant threat to advances in surgery globally. Due to the potential impact of AMR on SSI especially in LMICs, it is extremely important to include it in any discussion on the burden, prevention, and control of SSI. Analysis of AMR rates in one report revealed an overall rate of 21.6% for bacteria cultured from incision swabs.[14] Countries with low HDI had the highest rate of 35.9% while middle and high HDI countries had rates of 19.8% and 16.6%, respectively.[14] Unpublished data from a tertiary health facility in Nigeria over a 6-month period in 2018 showed high antibiotic resistance rates for bacteria cultured from surgical wounds with 92.3% of bacteria being resistant to ampicillin/sulbactam and 39.6% and 17.2% resistant to piperacillin/sulbactam and meropenem, respectively. In a study from Ethiopia, more than 75% of Gram-negative isolates from surgical wound specimens showed multiple antibiotic resistance while panbiotic resistance was noted among 34.8% of acinetobacter species and 12.5% of Escherichia coli.[18] Rational antimicrobial use and AMR surveillance are extremely important to stem the growing menace of AMR. Hope et al.[19] reported that in a regional referral hospital in Uganda, 86% of aerobic bacteria, 65.63% of Gram-positive isolates, and 96.72% of Gram-negative isolates from surgical wounds were multidrug resistant.

AMR increases mortality, morbidity, length of hospital stay, and overall health-care expenditure.[20] Morbidity and cost have been proposed as the most sensitive measures for quantifying the impact of AMR. In LMICs, where there is a high risk of catastrophic and impoverishing health expenditure, AMR further worsens the risk while also decreasing the availability of already scarce hospital beds by prolonging hospital stays.[21]

 Current Global Gaps in Surgical Site Infection

Lack of high-quality data on SSI in LMICs hampers advocacy and development of impactful interventions and policies. Studies on the economic impact of SSI on the population and its contribution to catastrophic and impoverishing expenditure are also grossly lacking in LMICs, the regions most affected by this scourge. There is currently no globally applicable risk stratification and no reliable projection of the impact of increasing the profile of AMR on SSI. There is, therefore, a need for the development of region and country-specific modalities for the implementation of available guidelines and methods for leveraging and coordinating interdisciplinary and intersectoral collaboration while ensuring surgeons' buy-in.

 Ongoing Efforts

The World Health Organization (WHO) Infection Control Campaign has emphasized the need to handle antibiotics with care in surgery, noting that misuse of antibiotics puts all surgical patients at risk.[22] This campaign showed that up to 33% of surgical patients get a postoperative infection of which 51% can be antibiotic resistant while 43% of patients have surgical antibiotic prophylaxis inappropriately continued after the operation.[22]

Appropriate antibiotic use in surgery requires multispecialty efforts and involves others such as pharmacists, infectious disease doctors, IPC team, senior managers, procurement staff, and patients and their families all of whom are not routine members of the surgical team.

The WHO Safe Surgery Initiatives using the safe surgery checklist includes efforts to control SSI. Uptake has, however, not been as universal as expected. Despite much advocacy, implementation in many parts of the world especially LMICs remains limited. The initiative's toolkit on antimicrobial stewardship also targets a reduction in infection and AMR rates. The deployment of this checklist needs to be strengthened.

 Investing in Surgical Site Infection Control and Benefits for Universal Health Coverage

The detrimental impact of SSI is compounded by the growing rates of AMR. While these lead to increasing morbidity and mortality the economic impact and the overall effect on already fragile health-care systems in LMICs are not fully appreciated. Without deliberate and targeted efforts to reduce the rates of SSI and AMR, the goal of UHC may not be fully realized due to their direct effect on increasing health expenditure and reducing access to in-hospital care for others as a result of prolonged hospital stays. It is crucial to urgently invest in the following activities:

Collate all available data and evidence on SSI into a single document to facilitate the planning of prevention and control, as well as the allocation and deployment of resourcesGenerate new primary data to better understand the dynamics of SSI and AMR in LMICsModel the public health impact of SSI to facilitate advocacy and investments.

These will help elevate the profile of SSI prevention and control globally, prioritize SSI prevention and control in global surgery and in the scale-up of access to surgical care, as well as generate needed funding for SSI research in LMICs.

 Potential Barriers

There are existing barriers in most LMICs that may impede progress in reducing SSI and AMR rates. Health-care funding remains a challenge. It is therefore important that innovative ways of funding SSI and AMR control activities be developed. Appropriate buy-in from country ministries of health is highly essential. Much advocacy may be necessary before this can be achieved. The attitude of health-care workers in these settings suggests a disposition that SSI is inevitable while easy access to and indiscriminate use of antibiotics by the population contribute immensely to AMR. These issues need to be appropriately addressed for meaningful progress in the prevention and control of SSI to occur.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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