Surgical site infection (SSI) is one of the most important causes of morbidity and mortality in postoperative patients. Even so, it can be prevented in most cases if proper assessment of resources and patients and appropriate measures are taken by surgeons, nursing staff and patients in the pre-operative, intra-operative and post- operative period [1-3].

Surgical site infections are clinically classified into those affecting the superficial tissues (skin and subcutaneous layer) of the incision and those affecting the deeper tissues (deep incision or organ space) according to the CDC definition [4,5]. A time period of 30 days after surgery was taken for an infection to be called an SSI in cases without implants, but it can extend up to a year in patients with implants [6,7]. SSIs are one of the major causes of morbidity and mortality in resource-limited countries, including India, despite recent advances in aseptic techniques [8,9].

Postoperative wound infections, now known as Surgical Site Infections (SSIs), result from bacterial contamination during or after a surgical procedure. The risk of wound infection is largely influenced by the degree of contamination, but there are other factors that contribute to the evolution of this process. These risk factors also play an important role in the occurrence of SSIs, which are investigated in this study [10-12].

The use of antibiotic prophylaxis before surgery has evolved greatly in the last twenty years. It is generally recommended in elective clean surgical procedures using a foreign body and in clean-contaminated procedures that a single dose of cephalosporin, such as cefazolin, cefotaxime, ceftriaxone etc. be administered intravenously in the operative suit just before incision. Surgical site infection still causes high morbidity and economic burden to the health care system [13-15].

We did an observational study at a tertiary care center to study prevalence of SSIs in general surgery and to determine various associated risk factors.

The aim of this study is to investigate the prevalence of surgical site infections and to determine different risk factors influencing the rate of SSI in a tertiary care hospital, Barabanki (U.P).

This observational study was carried out in the Department of General Surgery of Mayo Institute of Medical Sciences, Barabanki, Uttar, Pradesh, from July 2021 to June 2022.

Primary objectives: to study prevalence of SSI and to determine various risk factors influencing the SSI rate in general surgeries in a tertiary care hospital. Study design: an observational study. Study period: July 2021 to June 2022. Study setting: Department of General Surgery, Mayo Institute of Medical Sciences Barabanki, U.P., India.

Data was entered in Microsoft excel and was analyzed using SPSS version 16. Results were expressed in percentages. Chi-square test and multiple logistic regressions were applied to know the association between various risk factors and occurrence of SSI. Table 1 presents the prevalence of SSIs study cases (n =93).

Tables 2 and 3 present the study distribution of age and comorbidities.

Tables 4 and 5 present the distribution of smoking and alcoholism in the study.

Tables 6 and 7 show the types of anesthesia and surgery performed in this study.

Tables 8 and 9 show the distribution of SSIs according to the type of cancer, as well as the depth of the contaminated incision.

The most common surgery done in our study was hernioplasty. The present study contains 59 (63.44%) males and 34 (36.56%) females. Among all 93 patients, most patients were in the 40-50 age group (37.6%), and of these 31 are men (40.8% of all men in the study), while women are 4 (23.5% of all women in the study).

In our study, among the 8 patients with SSI, only 1 was a deep-incision SSI, while the remaining 7 patients developed superficial-incision SSIs.

There are more chances of developing SSI in emergency surgery than elective surgery (p=0.005, chi square-7.979). The P value is significant, so the nature of surgery is an independent risk factor associated with SSI in our study.

In our study, patients with comorbidity were 3,722 times more likely to develop SSI than patients without comorbidity (95% C.I. from 0.847 -16.357).

Alcoholic patients are 3,714 times more likely to develop SSIs than non-alcoholic patients (95% C.I. from 0.628 – 21.967). Emergency surgery have 7.187 times more risk of developing SSIs than elective surgery (95% C.I. from 1.554-33.233).

In our study cases, the prevalence of SSIs was 8.60% (8 cases developing SSI). Among these 8 patients, the most prevalent type is superficial incisional type, i.e., about 87.5%, followed by deep incisional type, i.e., 12.5%; no organ/space related to SSIs is observed.

Surgical site infections (SSIs) are clinically classified into infections affecting the superficial tissues of the incision (skin and subcutaneous layer), and those affecting deeper tissues (deep incision or organ space), according to the CDC definition [4,5].

Surgical Site Infections (SSIs), previously called post operative wound infections, result from bacterial contamination during or after a surgical procedure [10-12].

The present study includes 93 patients from department of general surgery in Mayo Institute of Medical Sciences, from July 2021 to June 2022. The obtained results reveal a prevalence of SSIs of 8.60%. Of the 93 patients suspected by surgical site infections, 8 patients were confirmed to have SSIs by CDC criteria and positive pus culture reports. Globally, SSI rates have been reported to range from 2.5 to 41.9% (depending on the study), with 15% SSIs reported by Reichman et al. in 2009 in their study [16].

In developed countries, SSIs rates have been reported to range from 1.2 to 5.2%, according to WHO 2011 [17,18]. Previous studies in India have shown SSI rates ranging from 4 to 30% [19].

The present study contains 59 (63.44%) males and 34 (36.56%) females. Among all 93 patients, most patients (35) were in the 40-50 age group, and of these 31 are men (40.8% of all men in the study) while women were only 4 (23.5% of all women in the study). In our study of 93 patients, among the 76 men operated on, 6 developed SSIs (7.89%), which is comparable to the study by Pathak et al. (2014), where men had an SSI rate of 5.3% (of 17 women operated on, only 2 developed SSI, i.e., 11.76%) [19]. These data are comparable to the 2017 study by Kumar et al. showing a female SSIs rate of 12% [20]. So, females are more likely to develop SSIs compared to males, which is comparable to the study of Khan et al., where females (27%) showed a higher prevalence of SSIs than males (18 %) [21]. However, according to Berard and Gandon, gender is not a predictor factor of SSI risk [22].

In the present study of 93 patients, 37 were non- smokers and 3 developed SSIs (8.10%), whereas among 56 smokers 5 developed SSIs (8.92%). So, there is not much difference in risk of developing SSIs among smokers and non-smokers, which is comparable with the 2014 study of Pathak et al., where SSI rates in smokers were 6.7% and 3.8% in non-smokers [19].

In our study, alcoholic patients have 3.714 times more risk of developing SSIs than non-alcoholic patients (95% C.I. from 0.628 – 21.967) and tobacco chewer have 1.829 times more risk of developing SSIs than non-tobacco chewer (95% C.I. from 0.402-8.309), which is comparable to the 2021 study of Bekiari et al. [23].

In the present study of 93 patients, 71 patients had no comorbidity, but 4 developed SSI (5.63%), while in 22 patients with associated comorbidity, 4 developed SSI (18.18%). So, patients with associated comorbidity have an increased risk of developing SSIs. In our study, patients with comorbidity were 3,722 times more likely to develop SSIs than patients without comorbidity (95% C.I. from 0.847 - 16.357). Comorbid conditions like anemia, diabetes and hypertension were the significant risk factors for SSIs. Our study is comparable to the study of Pathak et al. from 2014, in which the SSI rates in patients with comorbidities is 11.5%, and in patients without comorbidities is 4.8% [19]. National Academy of Science also reported higher rate of infection in patients with diabetes mellitus which is similar to our study [24]. Comparable results have been found in several studies involving different surgical procedures, such as: Xue et al. [25], Uzun et al. [26], or Giles et al. [27].

In the present study, 72 elective surgeries were performed, of which 3 developed SSIs (4.16%). Among 21 emergency surgeries, 5 subjects developed SSIs (23.80%). Emergency surgery have 7.187 times more risk of developing SSIs than the elective surgery (95% C.I. from 1.554-33.233). There is more chance of developing SSIs in emergency surgery than in elective surgery (p=0.005, chi square-7.979), which is comparable to the 2011 study by Satyanarayana et al. in which the SSIs rate was 7.6% in elective operations and 25.2% in emergency operations [28]. Similar results (with a higher rate of SSIs in emergency surgeries than in elective surgeries) were also reported in other studies, such as that of Lilani et al. from 2005 [29].

In our study, out of 32 patients who were operated under general anesthesia 5 developed SSIs (15.62%), while out of 61 patients who were operated under spinal anesthesia only 3 developed SSIs (4.9%). So, a patient with surgery performed under general anesthesia has a higher risk of developing SSIs compared to those operated under spinal anesthesia. There is no comparable study available in the literature review.

In our study, the prevalence of SSIs was 8.60%, that is, 8 cases developed this complication. Among these 8 cases, the most frequent were associated with the superficial incisional type (ie approximately 87.5%), followed by the deep incisional type (ie 12.5%). The data are comparable to the study by Lekshmi et al. from 2018, in which the frequency of SSIs was 91.8% for superficial incision, and 5.4% for deep incision [30].

Surgical site infections are the third most common hospital-associated infection, accounting for 14-16% of all inpatient infections. Among operated patients, surgical site infections are the most common cause of surgical infections, representing 38% of all postoperative infections. Despite all specific measures to maintain asepsis, most surgical wounds are considered to be contaminated to some extent. From this study, the following data emerged as possible measures to be adopted/improved in surgical interventions: reducing the duration of the operation by adopting appropriate surgical techniques and by permanent training of the staff, especially when new techniques or devices are used. Also, a judicious use of drains is recommended, and additional attention must be paid in the case of emergency surgical interventions, with a high potential for contamination, and which involve general anesthesia.