Incidence of Surgical Site Infections Highest in Lower-Income Countries

A large proportion of surgical site infections are caused by organisms resistant to prophylactic antibiotics, with the greatest apparent burden in low- and middle-income countries

Countries ranking lower on the United Nations Human Development Index (HDI) carry a disproportionately higher burden of surgical site infections (SSIs) and may have higher rates of antibiotic resistance, according to research published in the Lancet Infectious Diseases.1

A prospective, multicenter, cohort study was conducted, which included 12,539 patients from 343 hospitals in 66 countries undergoing elective or emergency gastrointestinal resection ( identifier: NCT02662231). Countries were stratified into high, middle, or low income according to the HDI, and 30-day SSI incidence and relationships with explanatory variables were investigated.

Overall, SSI incidence was 12.3% and varied between countries: 9.4% in high-HDI countries, 14.0% in middle-HDI countries, and 23.2% in low-HDI countries (P <.001). 

The highest SSI incidence in each HDI group was after dirty surgery (an incision undertaken during an operation in which the viscera are perforated or when acute inflammation with pus is encountered during the operation): 17.8% of patients in high-HDI countries, 31.4% in middle-HDI countries, and 39.8% in low-HDI countries.

After adjusting for risk factors, patients in low-HDI countries were at greatest risk for SSI (adjusted odds ratio, 1.60; 95% credible interval, 1.05-2.37; P =.030). Resistant infections were detected in 16.6% of patients in high-HDI countries, 19.8% of patients in middle-HDI countries, and 35.9% of patients in low-HDI countries (P <.001).

Incidence of SSI was consistently higher in low-HDI countries, even after adjusting for factors describing patients, diseases, procedures, safety, and hospitals. The highest rates of resistant infections were also found in low-HDI settings, and postoperative courses of antibiotics were longest for these patients. Although investigators did not recommend a change toward shorter antimicrobial treatments, an independent editorial published in the Lancet Infectious Diseases suggested that if resistance is an important contributor to SSI, then “an enhanced effort in antimicrobial stewardship will also need to be implemented.”2

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“Findings provide the rationale to plan, fund, and perform high-quality surgical research that can effect change in health policy,” especially in low- and middle-income countries, the investigators concluded.


  1. GlobalSurg Collaborative. Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study [published online February 13, 2018]Lancet Infect Dis. doi: 10.1016/S1473-3099(18)30101-4
  2. Sawyer RG, Evans HL. Surgical site infection—the next frontier in global surgery [published online February 13, 2018]Lancet Infect Dis. doi: 10.1016/S1473-3099(18)30118-X