Nosocomial or incubated on admission. Surgical Site Infections

Nosocomial Infections (Hospital Acquired Infections / HAIs) have become a significant burden worldwide. It has been simply defined as infections acquired during hospital care which has not been presented or incubated on admission. Surgical Site Infections (SSIs) or post-operative wound infections have been considered as one of the most prevalent hospital acquired infections in clinical setup (WHO, 2004).Surgical Site Infections (SSIs) have been defined as infections of the incision or organ or space that occur after surgery (CDC, 2017). However, defining an SSI needed evidence of clinical signs and symptoms of infection together with microbiological evidence since a variety of microorganisms have been normally colonized on our skin that could cause infections (CDC, 2016). An SSI has usually presented as a purulent discharge, abscess or spreading cellulitis at the surgical site during the month after the surgical procedure (WHO, 2002). Health and economic burden of SSIs reported to be considerably higher worldwide. According to the statistics of World Health Organization (WHO), SSIs have been the most surveyed and most frequent type of infection in low and middle income countries with incidence rates ranging from 1.2 to 23.6 per 100 surgical procedures and a pooled incidence of 11.8%. In contrast, in developed countries, SSI rates have been varied between 1.25% and 5.2% (WHO, 2011). Furthermore, several studies have stated that SSIs have been the 2nd or 3rd most nosocomial infection worldwide (CDC, 1999, Burke, 2003 & Sohil et al., 2006). Even in Sri Lankan clinical setup nosocomial SSIs have become common. A study that has been conducted in Sri Lanka regarding the Health Care Associated Infections, SSIs have been mentioned as the 2nd most frequent sites of Health Care Associated Infections (HCAIs) accounting 17% and becoming 2nd only to the urinary tract infections (34%) (Dharmaratne & Wickramasinghe, 2013). A similar study had stated that among 16.8% HCAI cases, 4% accounted for Surgical Site Infections (Marapana et al., 2014).”The Silent Killer: Nosocomial Infections” has been another name given for the SSIs, as its severity has been ranged from minor to major, it has become more common and has required all the resources of modern medicine to cure (Dryden, 2009). Even in an era of developing technology and availability of modern effective antibiotics, SSIs have still been considered to be a life threatening condition to patients all over the world. This has been proven with the data indicating that SSI has a 3% mortality rate & there have been 75% of SSI – related deaths directly associated with SSI (Larchmt, 2012). SSIs have not only been attributed to high mortality and morbidity rates, but also to additional burden on the hospital by directly contributing to increase duration of hospital stay of patients. It has contributed to increased readmission rates and ultimately increased economic costs required for patients’ care, wound management and infection control in hospitals. As stated by Fry (2002), the estimated cost of superficial SSIs by the National Health Service of the United Kingdom was < 400 dollars/case (nearly 61200 Sri Lankan Rupees) whereas it would be tens of thousands of dollars per case for a complex infection such as sternal infections following a cardiac surgery. In an era of developed medical sciences, where the underlying pathology of wound infections has well understood, still SSI management has become a significant area to be addressed in a health care facility. Varying of etiological agents causing SSIs, between operative procedures, different hospitals, different patients, and different surgeons and especially in different geographical regions could have become a reason for the SSI management to be complicated (Bony et al., 200 and Ameh et al., 2009).In order to reduce SSIs in an institution, having a good knowledge regarding possible risk factors that have been contributed to the occurrence of SSIs would also be of immense importance. Once the risk factors have been identified, suitable control measures to prevent SSIs could be implemented. Diabetes, obesity, cigarette smoking and coincidental colonization of bacteria in remote site leading to infections have been identified as several patient risk factors contributing to SSI prediction (Mangram et al., 1999). The National Institute for Health and Care Excellence clinical guidelines, UK (2008) has also affirmed that the risk of SSI has been increased due to the risk of endogenous or exogenous contamination and due to the diminishing of the efficacy of the general immune response such as diabetes, malnutrition or immunosuppressive therapy, chemotherapy or steroids. In addition to these, inappropriate use of broad spectrum antibiotics has become a cause for antimicrobial resistance (AMR) of pathogenic bacteria causing SSIs. It has also been evident from the data that AMR has been a key challenge faced by Sri Lankan clinical setup (Liyanapathirana & Thevanesam, 2016). The problem has been more complicated due to overcrowded hospitals, poor infection control practices and unsuitable usage of antimicrobial agents (Vikrant et al., 2015).Once the risk factors have been identified, in order to reduce possible SSIs in a particular institution, presenting possible solutions could be very important. One solution could be preparation of an antibiogram, so that initiation of treatments could be done immediately as possible. The hospital antibiogram has been considered as a periodic summary of antimicrobial susceptibilities of local bacterial isolates submitted to the hospital's clinical microbiology laboratory and there by formulating an antibiogram using patient specific culture & susceptibility data would be critical (Joshi, 2010).Antibiograms have been aided in clinicians to identify local susceptibility rates, to determine empirical antibiotic treatment and to monitor antimicrobial resistance trends over time within an institution. These antibiograms have been used in comparing microbial susceptibility rates across institutions & to track resistance trends (Joshi, 2010). Having a working knowledge on the most probable organisms and the prevailing antibiotic sensitivity/ resistance pattern could have been useful to start empirical treatments without getting benefits of gram stain, culture and other antibiotic sensitivity results. Furthermore, it improves the overall effectiveness of the hospital and eventually contributes to the better patients' care. Even though the SSIs have been seen universally, the etiological agents causing SSIs have been varied with geographical region, between various surgical procedures, between surgeons, from hospital to hospital or even in different wards of the same hospital (Owens & Stoessel, 2008). This has implied the possibility of isolating different strains of the same species having different antimicrobial resistance in different wards of a same hospital. This study has been focused to establish local data on the incidence of SSIs and identify possible patients' characteristics that have been contributed to the development of SSIs. As this type of a study has not been done in Sri Jayewardenepura General Hospital before, the findings could be useful for the surgeons and physicians in the hospital, to minimize SSIs and there by increase better patient care.  Considering all these factors, it is a clear proof that identifying bacteriological spectrum of surgical site wound infections and preparation of their antibiogram at Sri Jayewardenepura General Hospital within a particular time period would be essential.