Prevalence of surgical site infection in orthopedic procedures, in an institution in the municipality of Pereira, 2022

Introduction

The acquisition of healthcare-associated infections (HAI) is characterized by developing during the patient’s hospital stay and even after the hospital stay during the recovery period, as long as it is due to factors intrinsic to the hospitalization or medical treatment of the entity, as well as surgical techniques that require prophylactic treatment and medical vigilance.¹

Thus, surgical site infection (SSI) is referred to as healthcare-associated infection (HAI), because according to the WHO these can develop up to 30 days after having undergone surgery, and can involve skin, subcutaneous cellular tissue, organs and/or spaces that have not been manipulated in the procedure, but that were affected by the spread of the infection.² All this has been tried to decrease with the implementation of standard antibiotic prophylaxis, in which the aim is to prevent the possibility of developing an infection, in such a way that before the intervention drugs are administered to mitigate this complication, however and in spite of the efforts made in this situation, cases of SSI continue to occur.^3,4

SSIs have been considered as one of the most consequent nosocomial infections generally worldwide with a progressive increase due to bacterial pathogenicity and virulence that increase the defense against antimicrobials, likewise the number of users whose pathologies are of greater severity is increasing.⁵

Surgical site infection (SSI) represents a significant concern in the field of orthopedic surgery, especially in procedures involving the use of osteosynthesis material. SSI, a postsurgical complication, can have devastating effects on patients, prolong hospital stay, and increase health care costs.^6–8

In addition to intrinsic factors, such as patient comorbidities and procedural characteristics, extrinsic factors related to the surgical environment and sterilization practices play a critical role in the prevention of SSI in orthopedic procedures.^4,9,10

The surgical environment must be maintained under strict aseptic and infection control conditions. Cleaning and disinfection of the operating room, proper sterilization of instruments and surgical material, and rigorous adherence to aseptic techniques are essential.¹¹ Failure to comply with these practices may expose the patient to pathogenic microorganisms, significantly increasing the risk of SSI.

Additionally, the choice and handling of implants and osteosynthesis devices are crucial factors. Inadvertent contamination of these materials during the handling process can introduce microorganisms into the surgical site, potentially leading to SSI. Therefore, ongoing training of surgical personnel and constant vigilance.^6,7,12

In the context of Colombia, SSI in orthopedic procedures also represents a considerable challenge for the national health system. Although specific statistics may vary, data from the Colombian Ministry of Health and Social Protection suggest that SSI is a major concern in the country. The magnitude of the problem is even more evident when considering the economic and social impact of SSIs in terms of prolonged hospitalizations and the cost associated with the treatment of these complications.¹³

Despite the fact that new technology has developed constant infection control practices, surgical techniques and principles of antibiotic prophylaxis, today SSIs continue to be one of the main causes of morbidity and mortality. In the United States, about 50 million surgical interventions are performed every year and the National Nosocomial Infection Surveillance (NNIS) reports an incidence of surgical site infection of 14 to 16%.¹⁴

One of the problems that is in conjunction with the infection related to fractures are the complications in modern orthopedic trauma surgery, taking into account that even after the surgical intervention many patients usually suffer great infections in the surgical site having a significant effect on the recovery.^10,15 Consequently, due to these great complications that can entail with the life of the patients, guidelines and recommendations for the treatment of infection related to hand fractures are implemented with the AO (Association for the study of Osteosynthesis) allowing improvement in the results of clinical studies on the incidences of these infections thus reducing costs and reaching different treatment strategies resulting in effectiveness in patients.^6,16

Likewise, the studies demonstrate a relationship between the application of clinical guidelines and institutional protocols in an adequate manner, highlighting the importance and need to implement improvements within them according to the World Guide for the Prevention of Surgical Site Infection and national standards. In summary, the objective of this study is to evaluate the prevalence of surgical site infection in orthopedic procedures in an institution in the municipality of Pereira, Risaralda, Colombia in the year 2022. It is expected that this research will contribute to the improvement of the application of guidelines and clinical practices, so that with the findings the policies and each one of the procedures within the institution will be revised, improving and helping to reduce the prevalence of surgical site infection in orthopedic procedures, improving the quality of life of the users and reducing the costs associated with their reinterventions.

Methods

Quantitative, observational, descriptive, cross-sectional, retrospective study.

The population and sample is made up of patients who underwent orthopedic surgery in an institution in the municipality of Pereira, between January and December 2022.

Taking into account as inclusion criteria being older than 18 years who suffered closed fractures and required surgical management in the institution in the municipality of Pereira, having undergone an orthopedic procedure, Osteosynthesis with plates, screws and intramedullary nails, Open reduction of fractures with surgical wire and/or Kirchner nails, Patients who were infected patients with vascular diseases and patients diagnosed with diabetes mellitus type 1 or 2.

In addition, patients without follow-up, patients with intraoperative complications and patients more than 30 days after surgery were excluded.

The collection of information was achieved through the databases that were provided by the institution of the municipality of Pereira, after the review of clinical records relevant to the study, which was approved by the research committee of the faculty of health sciences under the project code SMIQ2022-10, and the epidemiology area of the health institution on March 9, 2022. Having sociodemographic variables such as age and sex, variables intrinsic to the patient such as the type of surgery to be performed, ASA classification, arterial hypertension, diabetes mellitus, vascular diseases, classification of the surgical wound, days of hospitalization and extrinsic variables such as the occurrence of infection and the duration of the procedure.

For data analysis, the data were tabulated in Microsoft Excel to verify the quality of the information in the database and the statistical SPSS^® Statistics, version 24 for statistical analysis. Descriptive statistics such as mean, standard deviation, minimum and maximum values for continuous variables and percentages for categorical variables will be used. Student’s t test or ANOVA will be used for the comparison of quantitative variables and X2 for categorical variables. A p < 0.05 will be determined as the level of statistical significance.

Results

The analysis of 13 medical records was carried out, where 69.2% corresponded to the female gender and 30.8% to the male gender (Table 1).

In relation to the type of superficial infection, there was a predominance in the female gender with 57.1%, while in the male gender it was 42.9%. Considering the deep infection, the female gender had a higher percentage with 83.3%, while he male gender had 16.7% (Table 2).

The type of antiseptic used showed a predominance of chlorhexidine in the female gender with 66.7%, while in the male gender it was 33.3%. In the case of iodopovidone foam, its use was exclusively in the female gender with 100.0%, while in the male gender its use was not recorded (Table 3).

Regarding the types of procedures, it was observed that hip arthroplasty was performed exclusively in the female gender with 100%, while in the male gender no cases were recorded. In the case of knee arthroplasty, the female gender represented 75%, while in the male gender it was 25%. In osteosynthesis, an equal percentage was recorded in both genders, 50%. In contrast, MAOS removal was performed only in the female gender with 100%, while in the male gender no cases were recorded (Table 4 and Figure 1).

Figure 1. Types of procedures.

Clinical variables were recorded showing that the female gender prevails in most of the pathological antecedents, such as vascular diseases, obesity and autoimmune diseases, all with 100.0%. Arterial hypertension showed 88.9% in the female gender, being the only variable with statistically significant importance. Diabetes mellitus was 75.0% in the female gender, while in the male gender there were no cases in any of the variables mentioned (renal failure, obesity, vascular diseases and autoimmune diseases). Arterial hypertension, COPD and diabetes were recorded below 50.0%, while asthma was 100.0% in the female gender (Table 5 and Figure 2).

Figure 2. Clinical characterization.

The ASA 1 classification was predominant in the male gender with 60%, while in the female gender it was 40%. In the ASA 2 classification, the female gender showed a predominance of 87.5%, while in the male gender it was 12.5% (Table 6).

In the classification of the clean surgical wound, the female gender had a predominance of 75.0%, while in the male gender it was 25.0%. In the dirty wound, the male gender had a percentage of 100.0%, while in the female gender no cases were recorded (Table 7).

Prophylactic antibiotics such as vancomycin, clindamycin, cefazolin and amikacin were administered, both together and separately. A greater use of cefazolin was observed in both the female and male genders, presenting greater resistance in the female gender with a percentage of 100.0% (Table 8; Figure 3 and Figure 4).

Figure 3. Antibiotic prophylaxis administered.

Figure 4. Antibiotic resistance.

Discussion

In response to the objective of the research, the discussion will be enhanced by taking into account other published studies that will help us to compare and detail the findings obtained in the data collection in an institution in the municipality of Pereira, on “the prevalence of surgical site infection in orthopedic procedures”.

The collection of information was achieved through the databases that were provided by the institution of the municipality of Pereira, corresponding to the month of January to December 2022, some of the main objectives are to characterize sociodemographically the population under study and clinically describe the users who underwent an orthopedic procedure in the population, and to identify the risk factors associated with surgical site infection in postoperative orthopedic procedures.

Among the participants of the study, an instrument was created to collect data indicating the use of antibiotics, thus sociodemographically characterized by collecting data such as name, age, sex, weight and date of admission, the type of procedure performed, day, time, surgical site, type of wound, adding the use or not of antibiotic prophylaxis, the amount and type used, as well as the start and termination of treatment.

The first study examined the prevalence of surgical site infections (SSIs) in orthopedic procedures, revealing a rate of 2.1%. Important risk factors were identified, such as prolonged duration of surgery, use of orthopedic implants, and number of fractures, highlighting the need for effective preventive strategies and careful management of surgical procedures.¹⁷

On the other hand, the second study focused on the incidence of surgical wound infections (SWI) in a more general context, showing a rate of 2.3%. Intrinsic risk factors such as arterial hypertension and overweight/obesity were highlighted, as well as independent risk factors, including comorbid diseases such as neoplasms, heart disease, renal failure and liver cirrhosis. The importance of adequate antibiotic prophylaxis and prevention of intraoperative blood transfusion was also emphasized.¹⁸

A study which was carried out in Madrid¹⁹ included a sample of 652 participants, identified a 2.1% incidence rate of SSI, which represents a significant problem in patient safety. In contrast, the second study, although with a smaller sample of 8 patients, showed a predominance of male gender in 75% of cases, with a mean age of 33.5 years, suggesting a possible specific predisposition of this demographic group towards a greater susceptibility to SSIs.

Furthermore, both studies underline the importance of temporal surveillance to detect the occurrence of signs and symptoms of SSI after surgical procedures, whereas the first study revealed a detection interval of 9 to 120 days after the procedure, the second study²⁰ highlighted those two patients presented symptoms simultaneously on day 15, representing 25% of the total patients analyzed. This emphasizes the need for close monitoring and follow-up for a prolonged period after orthopedic surgery.

Regarding the microorganisms associated with SSIs, the following microorganisms have been identified¹² the first study showed a higher prevalence of Staphylococcus aureus in 25% of the cases, while other microorganisms such as Enterobacter aerogenes, Pseudomonas oryzihabitans and Serratia marcescens were also identified in 12.5% each. On the other hand, the second study focused on the presence of Staphylococcus aureus, which represented 25% of the reported cases, suggesting a possible constancy in the presence of this pathogen in surgical infections. The variability in the identification of microorganisms may reflect differences in infection prevention and control protocols between institutions.

Regarding postoperative management, both studies highlight the importance of regular and timely healing. The first study indicated that 75% of the patients analyzed received the first healing between the first and fourth day after surgery, while the second study reported that one patient did not attend the ordered healing, representing 12.5% of the sample. These findings emphasize the need for consistent and appropriate care in the postoperative period to avoid complications arising from SSI.

Considering these studies together, the importance of implementing infection prevention and control strategies adapted to specific contexts is evident. Despite the differences in the risk factors identified, both studies highlight the importance of optimizing antibiotic prophylaxis and adequately managing specific comorbidities to reduce the incidence of postsurgical infections. In addition, attention to perioperative surveillance and surgical time management are suggested as key areas to improve surgical outcomes in both cohorts of patients, and these studies highlight the importance of rigorous surveillance, accurate identification of microorganisms and effective postoperative management, as they can contribute significantly to the reduction of the incidence of SSIs in patients undergoing orthopedic procedures.

Ethics and consent

We obtained scientific approval from the research committee of the faculty of health sciences under the project code SMIQ2022-10, and the epidemiology area of the health institution on March 9, 2022.

This study is a “research without risk”, according to resolution No. 8430 of 1993 of the Colombian Ministry of Health, which establishes the scientific, technical and administrative norms for health research, respecting the ethical principles of beneficence, non-maleficence and confidentiality of the Declaration of Helsinki.

Taking into account that for the type of study anonymized data is required, without address, telephone or identification of patients or records of the database, supporting us in the cited in the law 1581 of 2012 in its title III, Article 6°. Treatment of sensitive data. The treatment of sensitive data is prohibited, except when the treatment has a historical, statistical or scientific purpose. In this event, the measures leading to the suppression of the identity of the owners must be adopted.

The analysis is retrospective and through secondary bases and the information from the clinical records was provided by the health institution with the study variables extracted by them from the clinical history., for which informed consent was not required.