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 Table of Contents  
SYSTEMATIC REVIEW AND META-ANALYSIS ARTICLE
Year : 2019  |  Volume : 26  |  Issue : 3  |  Page : 143-151

Epidemiology of surgical site infections in Nigeria: A systematic review and meta-analysis


1 Department of Pharmaceutics and Pharmaceutical Microbiology, Usmanu Danfodiyo University, Sokoto, Nigeria
2 Department of Pharmaceutics and Pharmaceutical Microbiology, Ahmadu Bello University, Zaria, Nigeria

Date of Web Publication13-Aug-2019

Correspondence Address:
Mr. Ahmed Olowo-Okere
Department of Pharmaceutics and Pharmaceutical Microbiology, Usmanu Danfodiyo University, Sokoto
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/npmj.npmj_72_19

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  Abstract 

Introduction: Surgical site infection (SSI) is a major patient safety concern in hospitals. Unlike most developed countries, Nigeria does not yet have an established national system to monitor the occurrence of this infection. This meta-analysis was thus designed to determine the pooled cumulative incidence of SSIs and various determinants of its occurrence in Nigeria. Methods: The electronic databases were systematically searched for articles reporting the occurrence and risk factors associated with SSIs in Nigeria from January 2000 to December 2018. The eligible articles were evaluated using a set of pre-defined criteria. The extracted data were analysed using the comprehensive meta-analysis software. The Begg and Egger's regression tests were used to assess the risk of bias of the included publications. Results: Thirty-two articles emanating from the six geopolitical regions of Nigeria were included in this meta-analysis. The pooled cumulative incidence of SSIs was 14.5% (95% confidence interval [CI]: 0.113–0.184) with the highest incidence reported in the north-eastern region (27.3%, 95% CI: 0.132–0.481) of the country. It was also found to occur more predominantly following colorectal and abdominal surgeries, among elderly patients and in patients with co-morbid conditions. The most frequently reported was the superficial incisional SSIs occurring in 62.5% (95% CI: 0.333–0.848). Higher preponderance was also observed among patients with dirty wounds (52.7%, 95% CI: 0.367–0.682). Conclusion: This meta-analysis documents for the first time the national burden of SSIs in Nigeria. Control measures geared towards its reduction should be strengthened and a national policy on SSI surveillance, prevention and control developed.

Keywords: Epidemiology, infections, meta-analysis, surgical wound


How to cite this article:
Olowo-Okere A, Ibrahim YK, Olayinka BO, Ehinmidu JO. Epidemiology of surgical site infections in Nigeria: A systematic review and meta-analysis. Niger Postgrad Med J 2019;26:143-51

How to cite this URL:
Olowo-Okere A, Ibrahim YK, Olayinka BO, Ehinmidu JO. Epidemiology of surgical site infections in Nigeria: A systematic review and meta-analysis. Niger Postgrad Med J [serial online] 2019 [cited 2019 Oct 18];26:143-51. Available from: http://www.npmj.org/text.asp?2019/26/3/143/264392


  Introduction Top


Surgical site infection (SSI) just as other healthcare-associated infections (HCAIs) is a major patient safety concerns in hospitals. It tremendously impacts negatively on the patient's well-being as well as on the health-care personnel and financial resources for managing the condition. Despite the numerous preventive measures recommended for its reduction, SSIs continue to occur among surgical patients with substantial increase in the cost of healthcare, prolonged hospitalisation and jeopardised health outcomes.[1] It is sometimes associated with considerable morbidity and occasional mortality.[1] An approximate of 7–10 additional days on the length of hospital stay has been linked with SSI.[2],[3] The health-care cost for patients with SSI has been estimated to be twice that of the patients without SSI.[3],[4] Furthermore, an increased relative risk of death and readmission for patients with SSI compared to uninfected patients have been documented.[1],[5]

In the United States, against the third-most common nosocomial infections previously reported, SSI is now the most common nosocomial infection.[6] Approximately 77% death of surgical patients with SSI is reported to be related to the infection and majority resulted from serious infections involving organs or spaces accessed during the surgery.[6],[7] In Europe, the incidence of SSI varied from 0.6% to 9.5% depending on the type of procedure.[8] A 2010 prevalent survey by the Japanese HCAIs Surveillance showed that 7.6% of patients who underwent surgical procedures in Japanese hospitals developed SSIs.[9] In mainland China, a pooled cumulative incidence of 4.5% SSI has been reported.[10]

In developing countries, lack of expertise and resources required for effective surveillance of HCAIs limits the availability of data on the incidence of SSIs.[11] In sub-Saharan Africa, an overall incidence of 14.8% SSI has been reported.[12] Several studies had been conducted on the incidence of SSI in Nigeria.[13],[14],[15],[16] Majority of which involved a small number of patients admitted in a single healthcare facility and thus lack sufficient statistical power. As a result, findings from such studies cannot be generalised. Reliable and systematic data on the national prevalence and risk factors of SSI are therefore needed.

In the United States, the National Healthcare Safety Network is responsible for surveillance and collating data from the US hospitals on HCAIs.[17] In other developed nations such as the United Kingdom, Japan and China, similar national surveillance systems exist. In Nigeria, however, the corresponding body for monitoring of HCAIs has not been established. Thus, this meta-analysis was undertaken to determine the pooled cumulative incidence of SSIs and identify the various associated risk factors among surgical patients in Nigeria.


  Methods Top


Search strategy and study selection

A comprehensive search of PubMed, Africa Journals Online and World Health Organization Regional Database for Africa, Africa Index Medicus for published articles on the occurrence and risk factors of SSI in Nigeria from 1st January 2000 to 31st December 2018, was done. The search terms used were 'Surgical wound infection' or 'SSI' in combination with 'incidence' or 'occurrence' and 'predictor' or 'risk factors' and 'Nigeria'. In addition, a manual search of the bibliographies of the identified articles was performed to ensure no relevant article was inadvertently missed.

Two independent reviewers who were co-investigators evaluated the titles and contents of the abstracts for eligibility. Articles were evaluated according to the predefined criteria, and disagreements between the reviewers were resolved by consensus. Only full-text articles published in the English language on the epidemiology of SSI among humans during the period were considered for meta-analysis. The selection criteria are summarised below.

Inclusion criteria

  1. Studies that were conducted in Nigeria
  2. The studies that reported the incidence of SSI or provided original data, the number of SSI cases (n) and a total number of respondents (N), necessary to calculate the rate of SSI
  3. Observational studies, including both retrospective and prospective studies.


Exclusion criteria

  1. Duplicate articles or the same data used in two or more different studies
  2. Studies such as review articles, case reports, letters or editorial, conference summary/abstracts, and interventional studies were excluded from the study
  3. Studies in which the outcome of interest is the number and nature of surgical site pathogens with no data on the rate of SSI
  4. Studies, in which the sample size was <50
  5. Studies conducted outside the determined period of this systematic review.


Study identification

The retrieved references from databases were imported into Covidence (Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia). The duplicate articles were removed, and the remaining records were screened, first by title and then by abstract. The screening process was documented in the preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow chart of the study selection.

Data extraction

Data were carefully extracted from the included studies into a predesigned data collection form. The following data were obtained from each study: the first author's name, publication year, country, risk factors, numbers of SSI event and a number of patients that had the surgical procedure within the study. Authors of articles with incomplete metadata were contacted by E-mail for supplementary information.

Quality assessment

The quality of the included studies was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Studies Reporting Prevalence Data.[18] The JBI checklist contains nine items divided into sections on the representativeness of the study population, sample size, study setting and statistical analysis. The JBI scale ranges from 0 to 9 and a study with a score of six or more was considered to be high quality or have a low risk of bias.

Statistical analysis

The data collected were analysed using the the Comprehensive Meta-Analysis software (Comprehensive Meta-Analysis Version 3.3.070, Biostat Inc., Englewood, NJ, United States) All statistical tests were two-sided, and P < 0.05 were considered to be statistically significant.

The cumulative incidence, as well as its P value and confidence limits, were estimated from the unadjusted incidence rate of all included studies. Subgroup analyses were also performed to investigate potential sources of heterogeneity. Because of anticipated significant heterogeneity across studies, a random-effect model was used. This was represented using the forest plots and the I2 statistics was calculated to assess heterogeneity across studies using the following interpretation: I2< 50% indicated low heterogeneity, I2 50%–75% indicated moderate heterogeneity, and I2 > 75% indicated high heterogeneity. The risk of publication bias across the studies was assessed with a Begg's funnel plots and Egger's regression asymmetry test. In addition, the geospatial distribution of the occurrence of SSI in different parts of Nigeria was presented in GIS map built by using the Tableau Desktop Software, Professional Edition (Tableau Inc., Version 10.5.2, Seattle, WA. United States).


  Results Top


Identification of eligible studies

A total of 987 potentially relevant studies were identified and retrieved from the databases [Figure 1]. Additional 15 studies were obtained from other sources. Of the 987 relevant studies, 230 were duplicates and excluded. After the screening of the titles and abstracts, 676 references were considered irrelevant, and 96 articles considered of interest were assessed for full-text eligibility. Sixty-four full-text articles were excluded for various reasons. Overall, 32 studies were included in the meta-analysis.[2],[13],[14],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45],[46],[47] The detailed steps of the screening process are shown in a PRISMA flow chart of the study selection [Figure 1].
Figure 1: Preferred reporting items for systematic reviews and meta-analyses flow chart of study selection process

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Characteristics of the included studies

A summary of the study and patients' characteristics is presented in [Table 1]. This meta-analysis involved a total of 19,907 patients in 18 states of the federation including the Federal Capital Territory, Abuja. Each region of the federation was well represented. Majority of the studies were from the South-western region (9; 28.13%) followed by the North-western region (8; 25%). The distribution of SSI in the various regions and states of Nigeria was mapped and presented in the geospatial chart [Figure 2].
Table 1: The distribution of surgical site infection and stratified incidence according to the relevant characteristics of the study and the patients

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Figure 2: Forest plot of pooled incidence of surgical site infection by random-effects model

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An approximate 30 (93.7%) of the studies were conducted in a single health-care facility with only about 2 (6.2%) conducted in multiple centres, particularly by mobile surgical teams in rural communities. The analysis of the distribution of the health-care centres revealed that approximately 29 (90.6%) of the studies were conducted in tertiary health-care facilities with the remaining 3 (9.4%) in secondary health-care facilities and private hospitals. While the number of patients involved in each study varied from one study to another, a substantial number of the studies 15 (46.9%) involved >300 patients with some studies involving as high as 5000 patients. Three of the studies reported data exclusively on paediatric patients and eleven reported on the adult population. The remaining 18 studies reported data for patients in all age categories. In 17 of the 32 studies, SSIs were defined using the criteria stipulated by the United States Centre for Disease Control and Prevention. Other definitions used are the National Research Council and National Nosocomial Infection Surveillance while the definition was not specified in 12 articles.

Pooled cumulative incidence of surgical site infection

The cumulative incidence of SSI and stratified incidences according to the relevant characteristics of the study and the patients are summarised in [Table 1] and displayed at the individual-study level using a forest plot. Out of the 19,907 patients investigated between 2002 and 2018, 3047 developed SSIs, giving an estimated cumulative incidence of 14.5% (95% confidence interval [CI]: 0.113–0.184) [Figure 3]. The incidence of SSI ranged from 5.1% to 60.7% with a high level of heterogeneity between the studies (I2 = 97.42, P < 0.001). Funnel plot and Egger's test were performed to quantitatively access publication bias. Visual inspection revealed a symmetrical funnel plot [Figure 4] with Egger's regression intercept showing no existence of significant publication bias (P = 0.052).
Figure 3: Geo-spatial distribution of surgical site infection in the various states of Nigeria

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Figure 4: Funnel plot of standard error by logit event

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Subgroup analysis

A subgroup analysis revealed a statistically significant difference in the incidence of SSI between the regions of study and the study populations (P < 0.001) [Table 1]. SSIs were most commonly encountered following colorectal surgeries (29.2%, 95% CI: 0.216–0.382) and following abdominal surgeries (20%, 95% CI: 0.064–0.649), and among the paediatric populations (29.6%, 95% CI: 0.136–0.529). The highest incidence of SSI was reported in the north-eastern region (27.3%, 95% CI: 0.132–0.481) followed by the Northcentral region (26.3%, 95% CI: 0.116–0.493), whereas the lowest rate was reported in the south-south region (8.0%, 95% CI: 0.065–0.098) of the country. There is a statistically significant relationship between the occurrence of SSI and hospital rank (P < 0.0001), types of surgery (P < 0.0001) or surveillance period for SSIs (P < 0.0001).

As shown in [Table 2], the most frequently encountered type of SSI is the superficial incisional SSI, which occurred in 62.5% (CI: 0.333–0.848) of cases. The SSI incidence was also predominantly reported among patients with dirty wounds (52.7%, 95% CI: 0.367–0.682) and contaminated wounds (24.0%, 95% CI: 0.164–0.336). Similarly, the highest incidence of 18.62% SSI was reported among patients aged 60 years and above followed by an incidence rate of 16.91% among the patients aged <20 years.
Table 2: Subgroup analysis of surgical site infection in Nigeria

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The quality of the studies was generally acceptable with 27 high-quality studies, and only five studies revealed a low-quality score of 5.


  Discussion Top


Despite being a preventable complication of surgical procedures, SSIs continue to threaten public health with significant impacts on the patients and the health-care human and financial resources. Surveillance remains an important component of control and prevention policies. As high as 30%–50% of SSI can be reduced by surveillance and reporting.[48]

This meta-analysis revealed a high cumulative incidence of SSI in Nigeria (14.5%, 95% CI: 0.113–0.184). Our finding is comparable to the pooled cumulative incidence of 14.8% reported in a systematic review of SSI in sub-Saharan Africa.[12] This is, however, substantially higher than 4.5% reported in mainland China, 1.98% in the USA and up to 10% in Europe.[8],[10],[49] Differences in patients' characteristics make comparison between studies to be challenging and may partly be responsible for the observed high heterogeneity (97.4%) in this meta-analysis.[23] Other factors that may account for the high heterogeneity are variation in the study design and quality, SSI definition and the types of surgeries involved.[50]

The higher incidence of SSI reported in the Northern regions compared to the Southern region may be attributed to the differences in the socio-economic status of the people and the availability of health-care resources in the regions.[10],[51] The prevalent low-socio-economic status in most states in northern Nigeria compared to their southern counterparts has been widely documented, including a World Bank report.[52] It has been established that a low-socioeconomic level correlates to a higher risk of surgical wound infection.[42],[53] Furthermore, malnutrition is a common childhood disease in Nigeria and a common comorbidity among surgical patients. This is even more prevalent in northern Nigeria where close to 40% of the children has been shown to be malnourished compared to <15% in the southern regions of the country.[52] The potential impact of malnutrition on the immune system may have contributed to higher SSI rate recorded among patients in northern Nigeria.[54] A positive correlation between poor nutritional status and poor surgical outcomes has been established.[55]

In concordance with several other reports, the highest incidence of SSI was found among patients who had colorectal and abdominal surgeries. The large bowel, including the rectum, is loaded with a wide range of Gram-negative and anaerobic bacteria, which can easily spill to contaminate the operation field. These microbial pathogens are often resistant to the commonly used antibiotics in surgical practice, consequently resulting in a higher rate of SSI compared to the surgical procedures involving other organs.[56] This may also explain the preponderance of SSI among patients with dirty and contaminated wounds.

In line with the report of other workers, age, duration and nature of the surgical procedure, wound types and presence of co-morbid conditions such as anaemia, obesity and retroviral diseases were found to be significantly associated with higher risk of SSI. The risk of occurrence of SSI following emergency surgeries is about twice that the risk following elective surgeries. The high incidence of SSI among elderly patients and children has been attributed to the weakened immune system of the elderly and under-development of the immune system in children.[2],[57] In addition, factors indirectly related to age such as the increased prevalence of co-morbid conditions and increased severity of acute illness have been hypothesised as contributory to increased SSI risk in elderly patients.[58] It has been established that the majority of microbial pathogens implicated in SSI are acquired either endogenously or exogenously from the patients' environment.[6],[34] Longer duration of surgery would, therefore, increase the risk of surgical wound contamination due to the increased microbial bioburden of the operation field.[27] Although anaemia and smoking have been established as risk factors for SSI, these findings were, however, not supported by our meta-analysis results. Further studies are, therefore, required to corroborate this observation among Nigerian patients. Other factors identified to weaken patients' immunity include co-morbid status. This may also explain the prevalent of SSI among patients with BMI >25 and also among patients with diabetes mellitus observed in our meta-analysis. A linear association has been demonstrated between baseline BMI and the risk of developing diabetes mellitus.[59] Diabetes mellitus, in turn, has been shown to be significantly associated with increased risk of SSI.[60]

This meta-analysis is limited by a number of factors. First, we observed paucity of reports on the time until the onset of infections, post-discharge surveillance, morbidity and mortality associated with SSIs, and cost impacts of SSI. Second, this meta-analysis reports data from studies published in electronic databases. Several unpublished thesis and dissertations and articles published in traditional print journals could not be included in the meta-analysis because of lack of resources to search such databases. Third, this meta-analysis reports data mainly from studies conducted in tertiary health-care facilities (90.6%). Data from studies in secondary care facilities where infection control resources may be more limited and therefore have higher SSIs rate are rarely reported in literature Finally, the findings in this study may overestimate or underestimate the risk of SSI in Nigerian hospitals as only few of the studies used odds ratio to ascertain the association between risk of occurrence of SSI and various determinants. Despite these limitations, this meta-analysis is the first to explore the national burden of SSIs in Nigerian hospitals using appropriate statistical methods. The extensive sub-group analysis done on the various determinants of SSIs adds substantially to the robustness of this meta-analysis. Together, the information provided in this study will help enhance the awareness of SSIs and the epidemiological characteristics of these infections in Nigeria. Furthermore, we recommend the establishment of national policy document for the prevention and control of SSI in Nigeria and a national surveillance system to monitor the occurrence of HCAIs in Nigerian hospitals.


  Conclusion Top


This meta-analysis documents for the first time the national burden of SSIs in Nigeria. In view of the consistent association of SSI with some identifiable risk factors, control measures geared towards its reduction should be strengthened and a national policy on SSI surveillance, prevention and control should be developed.

Acknowledgement

We gratefully acknowledge the Library staff of Usmanu Danfodiyo University, Sokoto for their advice on retrieval of full-text publications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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