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. This trial is registered with ClinicalTrials.gov, number NCT02662231.
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> 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> 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.
Funding DFID-MRC-Wellcome Trust Joint Global Health Trial Development Grant, National Institute of Health
Research Global Health Research Unit Grant