Antibiotic usage link to surgery infection in low-income countries

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The increased likelihood of people having surgery in low-income countries developing an infection than those in wealthier nations, may be linked to drug-resistant bacteria, research suggests. Patients in low-income nations also have higher antibiotic use and are more likely to be infected with bacteria that are resistant to medicines, the study found. The findings shed light on a link between antibiotic use and infection and highlight an urgent need to tackle surgical infection in low-income nations, scientists say.

Infection at the site of a surgical wound is a complication that prolongs recovery times for patients and can be fatal. Until now, the extent of the problem in low income countries was unknown. To address this, researchers looked at hospital records – from 66 low-, middle- and high-income countries – for more than 12,000 patients undergoing surgery on the digestive system.

Patients in low income countries were 60% more likely to have an infection in the weeks following an operation compared with high and middle-income countries. Those who developed a wound infection were more likely to die, although the infection was not necessarily the cause of death. Infected patients were also found to stay in hospital three times longer.

Drug-resistant bacteria do not respond to antibiotics, making it hard to treat infection. Their spread has been linked to overuse of antibiotics and is an urgent global healthcare challenge.

The research was led from the Universities of Edinburgh, Birmingham, and Warwick as part of GlobalSurg Collaborative, an international network of doctors who gather healthcare data by recruiting healthcare centres through social media. It was funded by the National Institute of Health Research (NIHR).

Dr Ewen Harrison, clinical senior lecturer and honorary consultant surgeon at the University of Edinburgh, who led the research said: “Our study shows that low income countries carry a disproportionately high burden of infections linked to surgery.
“We have also identified a potential link between these infections and antibiotic resistance. This is a major healthcare concern worldwide and this link should be investigated further.”

Abstract
Background: Surgical 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.
Methods: This 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.
Findings: Between 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).
Interpretation: Countries 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.

Authors
Global Surgery Collaborative

University of Edinburgh material
Lancet Infectious Diseases abstract summary
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