Abstract
To the Editor:
We read the article “Reflections on the Complexity of Surgical Site Infection Prevention and Detection from an Organizational Lens” by Collins and Wick [1] with keen interest and would like to congratulate the authors for emphasizing the gaps in care in surgical site infection (SSI) prevention. In the present era, globally, we are dealing with the problem of emerging antimicrobial resistance with increased morbidity and mortality caused by SSIs, especially in low- and middle-income countries (LMIC) (2]. Inadequate drug regulatory mechanisms, inappropriate antibiotic usage, non-uniform perioperative practices, and inadequate patient follow-up are some of the major gaps seen as discussed by the authors in this article. We present a LMIC perspective in this response to the article by Collins and Wick [1].
The private sector is a major contributor of health care in LMIC, as is the scenario in the health care system in the United States, with nearly 80% of India's medical care being privately funded. This sector is largely unregulated in most LMICs and hence the gaps in perioperative as well as post-discharge care need to be highlighted for reducing rates of SSIs in these countries [3]. In this context, we share our experiences during the implementation of a multi-pronged intervention for an antimicrobial stewardship program (ASP) to prevent SSIs at a private tertiary care hospital in Mumbai, India, from the year 2014 to 2017.
We observed that adherence to protocols and best practices to minimize and prevent SSIs was missed in all the pre-, intra-, and post-operative areas of care, as mentioned by Collins and Wick [1]. Lack of adherence to good practices was important gap in SSI prevention. Inadequate or ineffective sterilization and poor hand hygiene within the operating theater were observed. There was a lack of maintenance of instrument sterilization logs with the use of appropriate indicators, and 45% of surgical team personnel performed inadequate hand washing. Only 20% of the cases received timely administration of antimicrobial agents within one hour of the surgery. The antimicrobial agents were administered in the morning of the surgery, on an average of three to four hours prior to surgery. We also observed that the prophylactic antibiotic agents were continued for as long as five days in the post-operative period.
As the authors mention, “vital information was lost during transit” from one stage of care to another. The direct and regular observation for 24–48 hours post-operatively was rarely practiced as a result of inadequate training of the surgical residents. There was lack of patient education regarding post-discharge incision care and timely follow-ups.
The issues need to be addressed effectively by applying the World Health Organization (WHO) checklist-based interventions to ensure knowledge and compliance with best surgical practices. This involves close coordination between various departments involved in the process of surgical care, including sterile supply division, operating room and personnel, infection control committee, and pre- and post-operative care in the inpatient departments [4], as also advocated by the authors Collins and Wicks [1].