Surgical site infection after gastrointestinal surgery in children: an international, multicentre, prospective cohort study

Abstract

Introduction: Surgical site infection (SSI) is one of the most common healthcare-associated infections (HAIs). However, there is a lack of data available about SSI in children worldwide, especially from low-income and middle-income countries. This study aimed to estimate the incidence of SSI in children and associations between SSI and morbidity across human development settings.

Methods: A multicentre, international, prospective, validated cohort study of children aged under 16 years undergoing clean-contaminated, contaminated or dirty gastrointestinal surgery. Any hospital in the world providing paediatric surgery was eligible to contribute data between January and July 2016. The primary outcome was the incidence of SSI by 30 days. Relationships between explanatory variables and SSI were examined using multilevel logistic regression. Countries were stratified into high development, middle development and low development groups using the United Nations Human Development Index (HDI).

Results: Of 1159 children across 181 hospitals in 51 countries, 523 (45·1%) children were from high HDI, 397 (34·2%) from middle HDI and 239 (20·6%) from low HDI countries. The 30-day SSI rate was 6.3% (33/523) in high HDI, 12·8% (51/397) in middle HDI and 24·7% (59/239) in low HDI countries. SSI was associated with higher incidence of 30-day mortality, intervention, organ-space infection and other HAIs, with the highest rates seen in low HDI countries. Median length of stay in patients who had an SSI was longer (7.0 days), compared with 3.0 days in patients who did not have an SSI. Use of laparoscopy was associated with significantly lower SSI rates, even after accounting for HDI.

Conclusion: The odds of SSI in children is nearly four times greater in low HDI compared with high HDI countries. Policies to reduce SSI should be prioritised as part of the wider global agenda.

Keywords: gastro-enterologic surgery; paediatrics.

Figure 1

Participant inclusion flow chart. HDI, Human Development Index; SSI, surgical site infection.

Figure 2

Multilevel, multivariable models for 30-day surgical site infection (SSI) in patients undergoing non-appendicitis surgery (A) or surgery for appendicitis (B). ASA, American Society of Anesthesiologists.

Figure 3

Relationship between HDI rank and probability of SSI (with rank 1 being most highly developed). adjusted for patient-level risk factors including age, sex, use of who checklist, antibiotic prophylaxis, intraoperative contamination and use of laparoscopy. HDI, Human Development Index; SSI, surgical site infection.