SummaryBackgroundSurgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world.MethodsThis international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231.FindingsBetween Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p<0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p<0·001).InterpretationCountries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication.FundingDFID-MRC-Wellcome Trust Joint Global Health Trial Development Grant,...

Summary Background 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov , NCT03471494 . Findings Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding National Institute for Health Research Global Health Research Unit.

No abstract

Background Surgical site infection (SSI) is defined as operation-related infections that occur at or near surgical incisions within 30 days after surgery. SSI is the most common postoperative complication and leads to increased morbidity and mortality among surgical patients. In Palestine, prospective multicentre studies on the epidemiology of SSI are lacking. We aimed to describe SSI epidemiology following gastrointestinal surgery in Palestine. Methods We used data from an international study (GlobalSurg 2), which is a prospective, multicentre cohort study. The 11 participating hospitals (four in the Gaza Strip and seven in the West Bank) provided a 30-day follow-up for consecutive gastrointestinal surgical operations performed during a 2-week period between Jan 1 and July 31, 2016, with the follow-up for the last period ending on Aug 30, 2016. 30-day follow-up data collection included incidence of SSI or other hospital acquired infection, any unexpected re-intervention and 30-day mortality. The primary outcome was the occurrence of SSI within 30 days of surgery, and secondary outcomes were 30-day postoperative mortality rate and administration of perioperative antibiotics. We used RedCap for data management, and SPSS for data analysis. Ethics approval was obtained from the Palestinian Ministry of Health. Findings Data were included for 249 patients; 133 (53•4%) were male and the mean age was 29 years (SD 17). Of these individuals, 43 patients (17%) were current smokers, 13 (5%) had diabetes, and 197 (79%) were rated as healthy according to the American Society of Anaesthesiology classification. Of the operations, 142 (57%) were emergencies, 224 (90%) were clean-contaminated, 186 (75%) were open surgeries, and 144 (58%) involved appendectomy. Antibiotics were given preoperatively to 79 patients (32%) and at the point of incision to 128 (51%). In total, 24 patients (10%) developed SSI and 3 (1%) had an intra-abdominal or pelvic abscess. The average length of in-hospital postoperative stay was 3 days (SD 2•5). One patient (0•4%) died within 30 days of surgery (30-day mortality rate). Interpretation We observed a low rate of SSI (10%) and 30-day postoperative mortality rate (0•4%) compared with other low-income and middle-income countries (SSI rate of 23•2% to 14•0%, 30-day postoperative mortality rate of 4•8% to 1•6%, for low-income to middle-income countries, respectively). This may be attributable to the fact that most of our cases were healthy and had clean-contaminated wounds. The results should be interpreted cautiously because of limited sample size and event rates.