Incidence And Predictors Of Surgical Site Infections And Associated Post-Operative Outcomes Along With The Malnutrition Risk Assessment At A Tertiary Care Hospital In Malaysia.
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Date
2016-12
Authors
Khan, Omaid Hayat
Journal Title
Journal ISSN
Volume Title
Publisher
Universiti Sains Malaysia
Abstract
At present, a comprehensive surgical surveillance data pertaining predictors of surgical site infection (SSI) in general surgery has not been documented before in Malaysia. Present study investigates the current surgical-care practices regarding SSI along with emphasis on malnutrition risk assessment and its impact on post-operative outcomes at a tertiary care hospital in Malaysia. A prospective observational study was conducted in general surgery, urology and neurosurgical departments between August 2014 and January 2015. Out of total 426 surgeries performed during the study period, only 216 cases met the inclusion criteria. Both male (n=113) and female (n=103) patients between 18-75 years of age were serially enrolled and were stratified according to the National Nosocomial Infection Surveillance (NNIS) and Study on Efficacy of Nosocomial Infection Control (SENIC) risk indexes. Both in-patient and post-discharge surveillance methods were used. Each patient was also screened for malnutrition risk by two independent risk assessment tools, Malnutrition Universal Screening Tool (MUST) and Nutritional Risk Index (NRI) as well as albumin in addition to the clinical assessment by a nutritionist, who was blinded to the results of the tools used. Furthermore, adherence of surgical prophylaxis was also compared to National Antibiotic Guidelines (NAG). Wide range of statistical tests were performed using SPSS version 20 for each objective. Twenty-eight (13%) out of 216 patients were SSI positive. Out of which 22 (78.6%) were superficial incisional SSI and 6 (21.4%) were deep incisional SSI. Median time to develop SSI was 6 days. There was an increasing trend of SSI from lower to a higher within surgical wound classification, NNIS risk indexes and SENIC risk indexes, American Society of Anesthesiologist score and malnutrition risk categories. Total length of stay in SSI patients was significantly longer as compared to non-SSI patients. Multivariate analysis revealed that ‘co-existing infection’, ‘patients at high risk of malnutrition according to MUST tool’, ‘patients at risk with NNIS risk index’, ‘post-operative length of hospitalization’, and ‘surgery duration > 2 hours’ are the independent risk-factors of SSI. Surgical prophylaxis was given in 160 (74.1%) patients, out of which 139 (86.9%) received a rational prophylaxis. Adherence rate to the NAG for the appropriate choice, dose, timing, re-dosing, and duration of prophylactic antibiotic was 57.5%, 75%, 88.1%, 88.8%, and 69.4% respectively. Prevalence of malnutrition in the current population was 35.6% (n=77) and Receiver Operating Characteristics (ROC) curve analysis showed that MUST was able to perform well (ROC Area under curve: 0.838 vs 0.748 for NRI and 0.792 for albumin) in correctly identifying patient at risk of malnutrition. Moreover, MUST also showed statistically promising results in predicting post-operative outcomes such as SSI, increased hospital stay, and mortality. In conclusion, high rate of SSI reflects inadequacies in the current infection-control policy or its implementation including inappropriate antibiotic utilization. Current study delivers valuable information and modifiable predictors to help optimize surgical-care practices in future. Furthermore, obtained results suggest the utilization of quick, easy, and affordable tool like MUST in order to assist health-care providers in identifying and managing their patients at malnutrition risk, thus further optimizing the quality of health-care environment.
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Keywords
Impact on post-operative outcomes , at a tertiary care hospital in Malaysia