Surgical site infection is professionally defined as appearance of pain at the site of wound, which is followed by redness, inflammation and site tenderness or presence of puss at infection site(1). The most common wound clean-contaminated and contaminated in abdominal surgery is that of laparotomy(2). According to Nichols, after abdominal surgeries, wound infections remain is the major source of illness. Among 27 million surgeries there were 500,000 numbers of infected patients. This rate can be decreased by considering use of incise drapes, injection perioperative prophylactic antibiotics and regardless of good surgery technique if the wound becomes infected then it should be left open(3). Nurses play a very most role in minimizing and managing wound infection. Surgical site infection can also be reduced by handling surgical instrument with caution and by implying best standards of practice(4). This can also help in the reduction of morbidity and mortality related to surgical site infection. Surgeries can be elective but mostly they are done in emergency (4, 5). As now awareness in increasing in people day by day, therefore before going for surgery people do have information on how the procedure will be done but they do not considered the side effect and post-operative complications(6). Longer the patient stay in the hospital, there chance of site infection increases. An infection after surgery occurs in up to 5% of surgical patients. Surgical site infection starts when the bacteria enter the wound. There are two mode of transferring bacteria(7). First one is by contact from surgeon, nurses or anything within hospital. Second is through airborne during surgery or after surgery(8). The most common form of bacteria attacking the site of infection includes streptococcus pyogenes, and staphylococcus aureus. There are two main sources of surgical site infection. First one is exogenous source and second is endogenous source. Mostly the infection occurs by patient`s own floral bacteria. Around 20% infection is caused by Staphylococcus aureus, 14% is caused by Coagulase negative staphylococcus and 12% is caused by Enterococcus(9, 10).

There are also some other factors which contributes in surgical site infection after operation. First of these factors are diabetes; if the glucose levels are high in the immediate surgery then it is associated with a high risk of surgical site infection(11). Other diseases are cancer or lung conditions which can delay the healing process and contributes in wound site infection. Another factor which contributes in surgical site infection is weak immune system. Immune system is that system of body which fights with infection causing foreign body(12). Severe malnutrition of protein-calorie is linked with delayed healing and contributes in causing infection(7). The immune system can become compromised by radiation, malnutrition and some medication such as steroids and anti-cancer. Age and weight can also contribute in the strength of immune system(13).

This study was done to determine the prevalence of surgical site infection, complications and rate of death due to infection for clean-contaminated and contaminated abdominal surgeries at DHQ Teaching Hospital KDA Kohat khyberPakhtoon Khwa Pakistan. This was a prospective study. The duration of this study was from February to October 2023. This study included patients of all age groups and both genders admitted in the surgery department of DHQ Teaching Hospital KDA Kohat khyberPakhtoon Khwa Pakistan who were assessed as having clean-contaminated and contaminated wound.

All patients received the same dosage that was 1 gram of Ceftriaxone in adults through intravenous injection and in children less than 12 year 50 gram per kilogram body weight was given as a prophylactic antibiotic at the time when anesthesia was induced. All those patients were excluded who was suffering from jaundice, diabetes mellitus, complicated or advanced malignancy, patients above the age of 65 years, patients on steroids and patients with penetrating abdominal injury.

The peritoneum and fascia, which is collective called deep abdominal wall was closed with the help of non-absorbable, single filament suture number “0” or “1”. In children the abdominal wall was closed with needle entry not less than 1cm from superficial skin with monofilament suture number 2/0. The patients were checked on the 5^th day, 10^th day and 8^th day to examine for any complications associated with site infection. The data was collected through questionnaire forms.

A total of 95 patients both adults and children, who met the inclusive criteria, were admitted in the General Surgery Department of DHQ Teaching Hospital KDA Kohat for abdominal surgery, who were later assessed for clean-contaminated and contaminated wound. Out of 95 surgeries, 55 were emergency based surgeries and 40 were elective surgeries. All included patients were assessed on 5^th and 10^th post-operation day. 95% were available on 28^th post-operative day.

Table 1. Distribution of patients by age and sex

Table 1 show that 69 were males and 26 were females. The peak age was 20 to 30 which was accounted for 50% of patients. The extremes ages has minority of patients that comprises of 11.5%.

Table 2. Proportion of surgical site infection

Table shows that majority of patients were not infected on 28^th day of surgery. High number of patients acquired infection between 6^th to 10^th post operation days. 

Table 3. Complication following clean-contaminated and contaminated laparotomy wounds

Table 3 shows that the common complication found in clean-contaminated and contaminated abdominal surgeries site infection comprises of 78.9%, wound dehiscence rate was 96.8% and rate of death was 85%

Table 4. The common pathogens isolated from infected wounds

Surgical site infection is the most common complication associated with abdominal surgery for clean-contamination and contamination. Site infection rate reduced up to 20% if pre-operative antibiotics are given along with the good surgical technique. The complications for site infection can contribute to increased cost and prolong hospital stay.

Prolong hospital stay is due to the surgical site infection and can be costly for patients as well as the heath sector. This study does not discuss the cost for infected persons and hospital stay due to infection.

To reduce the rate of surgical site infection and its complications it is important to use good surgical technique and pre-operative prophylactic antibiotics. The site infection rate, in this study is 20% , which shows that it is in the range from 10% to 20% in most studies. This can be due to the standard surgical technique and also the use of pre-operative use of antibiotics. Ceftriaxone is effective against gram negative and positive micro-organism(14).

Study done by Wayi reported that susceptibility of Staphylococcus to; Methicillin was 100%, Erythromycin was 72.7%, Tetracycline was 85.7% and 100% resistant to Penicillin G. Sensitivity of Klebsiella species to; Ceftriaxone was 93.3%, Augmentin was 76.5% and Gentamycin was 64.7% and the susceptibility of Pseudomonas species was 100% with Ceftriaxone compared to 75% with Gentamycin(15).

The main reason of morbidity is site infection and wound dehiscence, both of which account 34% while death rate was 31.5%. Ule along with others in his research reported that site infection rate was 13.3% with no death rate(16). Another study on colorectal surgery on 169 patients done by McArdle and others found out the site infection rate of 17%(17). DiPiro along with other did study on colorectal procedure including 12,384 patients reviewed the higher rate that is up to 22% in site infection and 25% site infection in upper gastrointestinal surgery(18).

In a study by DJ Leaper with others on 696 patients reported higher rate of morality because of site infection that is 11.8% and 1.6% for patients with no site infection(19). A study done by JM Badia along with others on post-operative complications following gastric cancer surgery reported that morbidity associated with infection accounts for 17.07% with death rate of 13.33%(20). Another study done by RM Strobel along with others stated in terms of determining the morbidity and mortality attributable to surgical site infection that mortality associated with infected group is 7.8% and 3.5 % in uninfected group(21).

The most common factor which influences the development of wound dehiscence is surgical site infection and faulty surgical technique. In this study the wound dehiscence accounts for 3.1% and is associated with site infection. The reduced rate of wound dehiscence is because of the good suture technique which is the use of monofilament suture, which without tension enters from wound edge with 1 cm distance of needle(22). In a study done by Senbanjo and Ajayi stated that the frequency of abdominal wound dehiscence was 2.5%(23). A randomized trial of 861 patients done by Israelsson along with others associated with midline laparotomy wound closure with monofilaments , 1/0 continuous nylon suture and follow-up of 12 months(24). He reported a wound dehiscence of 0.6%. Another study done by Israelsson et al on 467 patients revealed the predisposing factor in suture technique which promotes the healing of midline laparotomy. In his procedures he closed wound by continuous, monofilament mass closure with follow up for 1 year and reported that site infection was 11%, wound dehiscence was 0.4% and both of these were associated with site infection(25).

This study shows that surgical site infection is most common complication associated with abdominal surgeries and it contributes in a high rate of deaths and complications. This study also determines that an induction of pre-operative prophylactic antibiotics in clean-contaminated and contaminated abdominal surgeries and a good surgical technique can reduces the rate of surgical site infection and its complications.

Interest of conflict

Another study is needed to assess the cost of surgical site infection in this hospital and to compare it with free health care and cost recovering under Health Sector Reforms.

There is also a need to assess incision herniation, which requires long duration of at least 1 year or more.

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