Identification of predictive factors for surgical site infections in gastrointestinal surgeries: A retrospective cross-sectional study in a resource-limited setting

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This article endeavors to investigate the predictive factors of SSIs following surgical interventions that involve the gastrointestinal (GI) tract within a single institution in a resource-limited setting. Methods Over seven years from June 2015 to June 2022, patients who underwent GI surgery and developed SSI were retrospectively matched with an unaffected case-control cohort of patients. Standardized techniques for wound culture, laboratory evaluation of bacterial isolates, and antibiotic susceptibility tests were employed. Logistic regression analysis was utilized to investigate the predictive factors associated with 30-day postoperative SSI occurrence. Results A total of 525 patients who underwent GI surgical procedures were included, among whom, 86 (16.4%) developed SSI and the majority of SSIs were superficial (74.4%). Escherichia coli was the most commonly isolated bacterium (54.4%), and a high percentage of multidrug-resistant organisms were observed (63.8%). In multivariate Cox regression analysis, illiteracy (Odds ratio [OR]:40.31; 95% confidence interval [CI]: 9.54-170.26), smoking (OR: 21.15; 95% CI: 4.63-96.67), diabetes (OR: 5.07; 95% CI: 2.27-11.35), leukocytosis (OR: 2.62; 95% CI: 1.24-5.53), hypoalbuminemia (OR: 3.70; 95% CI: 1.35-10.16), contaminated and dirty wounds (OR: 6.51; 95% CI:1.62-26.09), longer operation duration (OR: 1.02; 95% CI: 1.01-1.03), emergency operations (OR: 12.58; 95% CI: 2.91-54.30), and extending antibiotic prophylaxis duration (OR: 3.01; 95% CI: 1.28-7.10) were the independent risk factors for SSI (all p < 0.05). Conclusions This study highlights significant predictors of SSI, including illiteracy, smoking, diabetes, leukocytosis, hypoalbuminemia, contaminated and dirty wounds, longer operative time, emergency operations, and extending antibiotic prophylaxis duration. Identifying these risk factors can help surgeons adopt appropriate measures to reduce postoperative SSI and improve the quality of surgical care, especially in a resource-limited setting with no obvious and strict policy for reducing SSI. " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/12-733", "name": "Identification of predictive factors for surgical site infections..." } } ] } Home Browse Identification of predictive factors for surgical site infections... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Al-hajri A, Ghabisha S, Ahmed F et al. Identification of predictive factors for surgical site infections in gastrointestinal surgeries: A retrospective cross-sectional study in a resource-limited setting [version 3; peer review: 1 approved, 2 approved with reservations] . F1000Research 2024, 12 :733 ( https://doi.org/10.12688/f1000research.135681.3 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Revised Identification of predictive factors for surgical site infections in gastrointestinal surgeries: A retrospective cross-sectional study in a resource-limited setting [version 3; peer review: 1 approved, 2 approved with reservations] Abdu Al-hajri 1 , Saif Ghabisha https://orcid.org/0000-0002-7800-0890 1 , Faisal Ahmed https://orcid.org/0000-0001-7188-2715 2 , [...] Saleh Al-wageeh 1 , Mohamed Badheeb https://orcid.org/0000-0001-8797-6329 3 , Qasem Alyhari 1 , Abdulfattah Altam 4 , Afaf Alsharif https://orcid.org/0000-0002-7702-9333 5 Abdu Al-hajri 1 , Saif Ghabisha https://orcid.org/0000-0002-7800-0890 1 , [...] Faisal Ahmed https://orcid.org/0000-0001-7188-2715 2 , Saleh Al-wageeh 1 , Mohamed Badheeb https://orcid.org/0000-0001-8797-6329 3 , Qasem Alyhari 1 , Abdulfattah Altam 4 , Afaf Alsharif https://orcid.org/0000-0002-7702-9333 5 PUBLISHED 30 May 2024 Author details Author details 1 Department of General Surgery, School of Medicine, Ibb University of Medical Sciences, Ibb, Yemen 2 Department of Urology, School of Medicine, Ibb University of Medical Sciences, Ibb, Yemen 3 Department of Internal Medicine, Faculty of Medicine, Hadhramaut University, Hadhramau, Yemen 4 Department of General Surgery, School of Medicine, 21 September University, Sana'a, Yemen 5 Department of Gynaecology, School of Medicine, Jeblah University for Medical and Health Sciences, Ibb, Yemen Abdu Al-hajri Roles: Conceptualization, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Software Saif Ghabisha Roles: Conceptualization, Data Curation, Investigation, Software, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Faisal Ahmed Roles: Conceptualization, Data Curation, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Saleh Al-wageeh Roles: Data Curation, Investigation, Methodology, Resources, Software, Visualization Mohamed Badheeb Roles: Data Curation, Methodology, Software, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Qasem Alyhari Roles: Data Curation, Formal Analysis, Investigation, Supervision, Validation Abdulfattah Altam Roles: Data Curation, Funding Acquisition, Investigation, Supervision, Validation Afaf Alsharif Roles: Formal Analysis, Investigation, Methodology, Supervision, Writing – Original Draft Preparation OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Background Surgical site infection (SSI), albeit infrequent, drastically impacts the quality of care. This article endeavors to investigate the predictive factors of SSIs following surgical interventions that involve the gastrointestinal (GI) tract within a single institution in a resource-limited setting. Methods Over seven years from June 2015 to June 2022, patients who underwent GI surgery and developed SSI were retrospectively matched with an unaffected case-control cohort of patients. Standardized techniques for wound culture, laboratory evaluation of bacterial isolates, and antibiotic susceptibility tests were employed. Logistic regression analysis was utilized to investigate the predictive factors associated with 30-day postoperative SSI occurrence. Results A total of 525 patients who underwent GI surgical procedures were included, among whom, 86 (16.4%) developed SSI and the majority of SSIs were superficial (74.4%). Escherichia coli was the most commonly isolated bacterium (54.4%), and a high percentage of multidrug-resistant organisms were observed (63.8%). In multivariate Cox regression analysis, illiteracy (Odds ratio [OR]:40.31; 95% confidence interval [CI]: 9.54-170.26), smoking (OR: 21.15; 95% CI: 4.63-96.67), diabetes (OR: 5.07; 95% CI: 2.27-11.35), leukocytosis (OR: 2.62; 95% CI: 1.24-5.53), hypoalbuminemia (OR: 3.70; 95% CI: 1.35-10.16), contaminated and dirty wounds (OR: 6.51; 95% CI:1.62-26.09), longer operation duration (OR: 1.02; 95% CI: 1.01-1.03), emergency operations (OR: 12.58; 95% CI: 2.91-54.30), and extending antibiotic prophylaxis duration (OR: 3.01; 95% CI: 1.28-7.10) were the independent risk factors for SSI (all p < 0.05). Conclusions This study highlights significant predictors of SSI, including illiteracy, smoking, diabetes, leukocytosis, hypoalbuminemia, contaminated and dirty wounds, longer operative time, emergency operations, and extending antibiotic prophylaxis duration. Identifying these risk factors can help surgeons adopt appropriate measures to reduce postoperative SSI and improve the quality of surgical care, especially in a resource-limited setting with no obvious and strict policy for reducing SSI. READ ALL READ LESS Keywords Surgical site infection, gastrointestinal surgery, predictors Corresponding Author(s) Faisal Ahmed ( [email protected] ) Close Corresponding author: Faisal Ahmed Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2024 Al-hajri A et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Al-hajri A, Ghabisha S, Ahmed F et al. Identification of predictive factors for surgical site infections in gastrointestinal surgeries: A retrospective cross-sectional study in a resource-limited setting [version 3; peer review: 1 approved, 2 approved with reservations] . F1000Research 2024, 12 :733 ( https://doi.org/10.12688/f1000research.135681.3 ) First published: 23 Jun 2023, 12 :733 ( https://doi.org/10.12688/f1000research.135681.1 ) Latest published: 30 May 2024, 12 :733 ( https://doi.org/10.12688/f1000research.135681.3 ) Revised Amendments from Version 2 All reviewer comments were responded and most of them were acted on in revised manuscript. The revised manuscript only includes minor changes as the reviewer suggested including a revision in organisms responsible in Table 2, a paragraph regarding steps to reduce SSIs overall in gastrointestinal procedures, and a few suggestions by reviewers. All reviewer comments were responded and most of them were acted on in revised manuscript. The revised manuscript only includes minor changes as the reviewer suggested including a revision in organisms responsible in Table 2, a paragraph regarding steps to reduce SSIs overall in gastrointestinal procedures, and a few suggestions by reviewers. See the authors' detailed response to the review by Nicolas Troillet See the authors' detailed response to the review by Prakash Kumar Sasmal READ REVIEWER RESPONSES Introduction A surgical site infection (SSI) is a frequently encountered nosocomial infection that typically develops within 30 days of surgery. In cases where an implant is used, the timeframe for SSI occurrence can extend up to one year. 1 The estimated incidence of SSI is 0.5% to 3% worldwide, with a higher incidence reported in low-income countries, where SSI is estimated to be the most common healthcare-associated infection. 2 , 3 In addition to the socioeconomic status, surgeries that involve the gastrointestinal (GI) appear to have a higher SSI incidence, with reports indicating a 12%-30% incidence rate of such cases. The associated expenditure of increased hospitalization (7-11 folds), mortality, and morbidity (2-11 folds) force a higher emphasis on detecting such patients earlier in the course of their illness and identifying patients with a higher risk of developing SSI to improve the quality of care and minimize the cost. 4 , 5 Various factors have been studied concerning SSI, which can extend from socioeconomic status to preoperative settings and surgical approaches. 6 Certain non-modifiable risk factors include age, gender, immunosuppression, diabetes mellitus, obesity, or active smoking. Additionally, the pre-operative preparation, operation duration, and intra-operative techniques may impact the development of SSI, which is seen at a higher rate in emergent and septic surgeries. 3 – 5 SSI can be attributed to microorganisms that are derived from the patient’s skin flora or the surrounding environment. 1 In either scenario, the adherence of microorganisms to the surgical instruments can contaminate the incision. Contaminated surgical procedures pose an increased risk, particularly when multidrug-resistant microorganisms are involved. 6 Previous monocentric and retrospective studies in Yemen reported SSI rates of 2.2% and 31.7%. 7 , 8 However, there is limited information available about the extent of SSI and its predictive factors in low-income countries, such as Yemen. 7 , 8 This study aimed to investigate the SSI rate and its predictive factors among Yemeni patients who underwent GI surgeries in a resource-limited setting. Methods Study design A retrospective cross-sectional study was conducted to investigate the SSI rate in patients who underwent gastrointestinal surgery at Al-Thora Hospital, Ibb University, IBB, Yemen, between June 2015 and October 2022. We included 525 patients, from whom written informed consent was obtained. The study was approved by the Ethics Research Committees of Ibb University [ID: IBBUNI.AC.YEM.2023.75, on 03/03/2023]. Inclusion criteria Adult patients (≥18 years old), who had undergone either elective or emergency GI surgery at general surgery wards were included. Exclusion criteria Exclusion criteria were pregnancy, anticoagulation, incomplete or concealing data, non-bowel-related surgeries ( e.g. , hernia), postoperative complications within more than 30 days of surgery, or admission to another hospital. Data collection The study enrolled all eligible patients in consecutive order and utilized organized questionnaires to gather applicable information. This included demographics, including age, gender, educational level, body mass index (BMI), and place of residence, as well as health habits such as cigarette smoking and Khat chewing. In addition, comorbid conditions such as diabetes mellitus (DM), hypertension, chronic kidney, lung, and liver disease, history of malignancy, and preoperative blood transfusions were also documented. The American Society of Anesthesiologists (ASA) categorization system was used to measure preoperative physical state. Other information collected included the operative date, duration, wound nature, type, duration, anesthesia type, using the safety checklists, the urgency of surgery, readmission, reoperation, hair removal time, and details of preoperative antimicrobial administration (injection of amoxicillin and clavulanic acid 1.2 g for clean wounds and injection of ceftriaxone 1 g and metronidazole 500 mg for clean-contaminated wounds). Laboratory-collected data were white blood cell (WBC) counts, neutrophile percentage, and albumin levels. The study documented surgery-related complications ( e.g. , SSI, fistula) in addition to non-surgical complications such as pneumonia, urinary tract infection (UTI), sepsis, and myocardial infarction (MI). Culture results and antibiotic sensitivities were also recorded, with wound swabs and pus specimens collected using standard microbiological techniques and transported to the laboratory for sensitivity analysis. Additionally, we collected the National Nosocomial Infections Surveillance (NNIS) index for each patient. Definitions Based on the depth of infection, these SSIs were subsequently categorized into superficial (affecting the skin and subcutaneous tissue), deep (involving muscle and fascia), and organ space infections. 6 Wounds were classified into four categories depending on their level of contamination: clean, clean-contaminated, contaminated, or dirty-infected. The ASA score, which reflects the patient’s physical condition before the surgery, was determined through evaluation by the anesthesiologist using the ASA classification system. 9 The NNIS index considers three risk variables, each of which is worth one point: contaminated or dirty-infected surgical wound, ASA scores greater than 2, and operation length greater than T (where T is defined as the 75th percentile of the normal time for a surgical procedure). 9 The gastrointestinal cases were sorted into four categories (small bowel, large bowel, biliary, and pancreatic). 10 Leukocytosis was defined as a WBC count greater than 100 × 10 9 /L and hypoalbuminemia was defined as an albumin <3.5 g/dL. Study outcomes The primary outcome was the prevalence of postoperative SSIs determined by assessing culture-positive results which were assessed by infection prevention and control staff diagnosis, according to the criteria set forth by the United States Center for Disease Control (CDC). This definition included infections affecting the superficial, deep, and organ space tissues of the surgical incision. The incidence of SSI was determined by evaluating and following up on all patients for 30 days following their surgery, by systematic visits, starting from the date of the operation. 9 It is important to note that medical complications such as pneumonia, MI, and UTI were separately documented and reported, and were not included in the definition of SSI or postoperative surgical complications. The secondary outcome was investigating the predictive factors for SSIs. Variables and measures The outcome variable was SSI expressed as a binary variable: yes and no. Independent variables included Age (<60 years and ≥60 years), Sex (male and female), ASA score (Low [1 or 2] and High [3 or 4]), NNIS index (No risk, Low risk, Moderate risk, High risk), Surgical sites (Large bowel and Other gastrointestinal sites), Hospital stays (<5 days and ≥5 days), BMI (<30 kg/m 2 and ≥30 kg/m 2 ), Residency (Urban and Rural), Educational level (Educated and Illiterate), the Antibiotic time before surgery (<1 h and ≥1 h), hair removal time (<24 hours and ≥24 hours), WBC (<10×10 9 /L and ≥10×10 9 /L), Albumin (≥3.5 mg/dL and <3.5 mg/dL), Operative type (Elective and Emergency), Blood loss (<200 mL and ≥200 mL), Anesthesia type (Spinal and General), Wound class (I and II and III and IV), Temperature (<38°C and ≥38°C), and Operation duration (min). Additionally, Khat chewing, Smoking, History of hypertension, History of diabetes, History of chronic renal failure, History of chronic liver disease, History of lung disease, Perioperative blood transfusion, History of malignancy, Safety checklist used, and Drain insertion were presented as “yes” and “no”. Statistical analysis IBM SPSS version 22 software (IBM Corp., Armonk, New York) was used for statistical analyses. Quantitative variables were presented as means and standard deviations, while qualitative variables were reported as frequencies and percentages. The normality of the data was confirmed using the Kolmogorov-Smirnov test. Statistical tests were used to compare qualitative and quantitative variables, including the independent samples t-test or Mann-Whitney test for quantitative variables, and the Chi-square or Fisher’s exact test for qualitative variables. All the continuous variables were converted into categorical variables for a better presentation of the nomogram. Univariate analysis was conducted to identify the statistically significant variables associated with the development of SSIs. First, we did univariate logistic regression to determine the potential variables for SSI. When the P-value<0.05, the corresponding variable would be considered statistically significant. Second, Spearman’s rank correlation coefficient was used to analyze the correlations between statistically significant variables. If correlation coefficients>0.700 between different variables, the strongly correlated variables would be removed. To detect collinearity, the variance inflation factor (VIF) was calculated. If VIF>3.000 or tolerance<0.100, the corresponding variable would be removed. Next, we conducted a multivariate logistic regression analysis of all the statistically significant variables to examine their independence. The links between each risk factor and SSI were presented as an odds ratio (OR) and confidence interval (CI). A p-value of less than 0.05 was judged statistically significant. The ROC curve (receiver operating characteristic curve) was utilized to evaluate the risk adjustment prediction performance of the previous NNIS risk index and the Author’s model for post-gastrointestinal SSI, which contains the significant factors in multivariate analysis. 9 Results Characteristics and presentation of patients This study included a total of 525 patients, comprising 295 (56%) male patients and 230 (44%) female patients, with a mean age of 52.9±16.9. Table 1 provides a summary of the patients’ characteristics and presentation. The postoperative 30-day SSI occurred in 86 (16.4%) patients. A total of 193 (36.8%) of patients had ASA Class One. The operative case distribution was 206 (39.2%) in the small bowel, 182 (34.7%) in the large bowel, 124 (23.6%) in the biliary system, and 13 (2.5%) in the pancreatic system. The mean operation duration was 76.4±28.2 minutes. General complications were UTI and pneumonia in 5.5%, high-grade fever in 5.1%, and MI in 1% of patients. Laboratory and operative characteristics of patients are mentioned in Table 2 . Table 1. Patient characteristics of 525 patients who underwent gastrointestinal procedures. Variables N (%) Age (year), Mean (SD) 52.2 (15.7) Sex Male 295 (56.2) Female 230 (43.8) Education level Illiterate 200 (38.1) Primary school 203 (38.7) High school 122 (23.2) Residency Urban 94 (17.9) Rural 431 (82.1) Body mass index (kg/m 2 ) 18.5-24.99 178 (33.9) 25-29.99 250 (47.6) >30 97 (18.5) American Society of anesthesiologists’ class 1 193 (36.8) 2 178 (33.9) 3 123 (23.4) 4 31 (5.9) Fever (Temperature ≥38°C) 251 (47.8) Current smoking status 281 (53.5) History of Hypertension 158 (30.1) History of Diabetes 108 (20.6) History of chronic renal disease 76 (14.5) History of chronic liver disease 48 (9.1) Hair removal time ≥24 hours of surgery 306 (58.3) History of lung disease 26 (5.0) History of malignancy 39 (7.4) History of Khat chewing 425 (81.0) Operative type Elective 202 (38.5) Emergency 323 (61.5) Time of prophylaxis antibiotic injection During 1 hour of operation 346 (65.9) More than one hour of operation 179 (34.1) Operative case Small bowel 206 (39.2) Large bowel 182 (34.7) Biliary 124 (23.6) Pancreatic 13 (2.5) Table 2. Laboratory and operative characteristics of 525 patients who underwent gastrointestinal procedures. Variables N (%) Hypoalbuminemia (albumin <3.5) 69 (13.1) Leukocytosis, Mean (SD) 24479 (48) Neutrophil ≥85% 283 (53.9) Anesthesia type Spinal 131 (25.0) General 394 (75.0) Safety checklists Used 471 (89.7) Wound calcification Clean 197 (37.5) Clean-contaminated 168 (32.0) Contaminated 123 (23.4) Dirty 37 (7.0) Blood loss ≥200 ml 102 (19.4) <200 ml 423 (80.6) Drain insertion 508 (96.8) Operation duration (min), Mean (SD) 76.4 (28.2) Hospital stays, (day), Mean (SD) 5.4 (1.7) 30-day postoperative surgical site infection 86(16.4) General complication Urinary tract infections 29 (5.5) Pneumonia 29 (5.5) High-grade fever 27 (5.1) Myocardial infarction 5 (1.0) Causative pathogens Pathogens linked with SSI were identified from all SSI patient wounds. Escherichia coli (51.2%), Enterococcus spp. (17.4%), Bacteroides species (9.3%), and Clostridium perfringens (8.1%) were the most commonly isolated micro-organisms, with more than half of pathogenicity (63.8%) being multidrug-resistant organisms and the majority (70.1%) being extended-spectrum β-lactam producers ( Table 3 ). The majority of SSIs were superficial infections 64 (74.4%), while deep SSI infection was presented in 14 (16.3%), and organ-specific SSI infection was seen in 8 (9.3%) of cases. Table 3. Distribution of pathogens identified in surgical site infections. Culture result N (%) Hepatobiliary tract (%) Large bowel tract (%) Small bowel tract (%) Escherichia coli 44 (51.2) 10 (40.0) 21 (67.7) 13 (43.3) Enterococcus 15 (17.4) 4 (16.0) 5 (16.1) 6 (20.0) Bacteroides species 8 (9.3) 4 (16.0) 2 (6.5) 2 (6.7) Clostridium perfringens 7 (8.1) 2 (8.0) 3 (9.7) 2 (6.7) Pseudomonas aeruginosa 5 (5.8) 2 (8.0) 0 (0.0) 3 (10.0) Klebsiella 4 (4.7) 2 (8.0) 0 (0.0) 2 (6.7) Anaerococcus prevotii 3 (3.5) 1 (4.0) 0 (0.0) 2 (6.7) The relationship between variables and SSI occurrences The relationship between the independent factors and the dependent variable was explored using univariate and multivariate Cox regression analysis. On univariate analysis, Khat chowing, high ASA class (3 or 4), smoking, hypertension, diabetes, hypoalbuminemia, illiterate, contaminated and dirty wounds, higher temperatures ≥38°C, leukocytosis, neutrophile ≥85%, longer operation duration, blood loss more than 200 mL, biliary and pancreatic cases, longer hospital stay, hair removal ≥24 hours of surgery, presence of NNIS risk index, and emergency surgery were statistically significant associations with SSI occurrence (all p<0.05) ( Table 4 ). Table 4. Univariate analysis of risk factors associated with surgical site infection. Factors Subgroup No SSI (n = 439) SSI (n = 86) OR (95%CI) P value Sex Male 249 (84.4) 46 (15.6) Reference group 0.581 Female 190 (82.6) 40 (17.4) 1.14 (0.71-1.81) Age groups <60 years 299 (84.5) 55 (15.5) Reference group 0.452 ≥60 years 140 (81.9) 31 (18.1) 1.20 (0.74-1.94) BMI (kg/m 2 ) <30 359 (83.9) 69 (16.1) Reference group 0.736 ≥30 80 (82.5) 17 (17.5) 1.11 (0.60-1.94) Residency Urban 80 (85.1) 14 (14.9) Reference group 0.667 Rural 359 (83.3) 72 (16.7) 1.15 (0.63-2.21) Educational level Educated 296 (91.1) 29 (8.9) Reference group <0.001 Illiterate 143 (71.5) 57 (28.5) 4.07 (2.51-6.71) Khat chewing No 94 (94.0) 6 (6.0) Reference group 0.003 Yes 345 (81.2) 80 (18.8) 3.63 (1.66-9.57) Smoking No 240 (98.4) 4 (1.6) Reference group <0.001 Yes 199 (70.8) 82 (29.2) 24.72 (10.08-82.01) History of hypertension No 286 (77.9) 81 (22.1) Reference group <0.001 Yes 153 (96.8) 5 (3.2) 0.12 (0.04-0.26) History of diabetes No 373 (89.4) 44 (10.6) Reference group <0.001 Yes 66 (61.1) 42 (38.9) 5.39 (3.28-8.89) History of chronic renal failure No 379 (84.4) 70 (15.6) Reference group 0.236 Yes 60 (78.9) 16 (21.1) 1.44 (0.77-2.60) History of chronic liver disease No 399 (83.6) 78 (16.4) Reference group 0.955 Yes 40 (83.3) 8 (16.7) 1.02 (0.43-2.16) History of lung disease No 417 (83.6) 82 (16.4) Reference group 0.888 Yes 22 (84.6) 4 (15.4) 0.92 (0.27-2.49) Antibiotic time before surgery <1 h 292 (84.4) 54 (15.6) Reference group 0.506 ≥1 h 147 (82.1) 32 (17.9) 1.18 (0.72-1.89) Perioperative blood transfusion No 408 (83.4) 81 (16.6) Reference group 0.676 Yes 31 (86.1) 5 (13.9) 0.81 (0.27-1.98) Hair removal time before surgery <24 h 199 (90.9) 20 (9.1) Reference group <0.001 ≥24 h 240 (78.4) 66 (21.6) 2.74 (1.63-4.77) History of malignancy No 405 (83.3) 81 (16.7) Reference group 0.534 Yes 34 (87.2) 5 (12.8) 0.74 (0.25-1.78) Temperature <38°C 248 (90.5) 26 (9.5) Reference group <0.001 ≥38°C 191 (76.1) 60 (23.9) 3.00 (1.84-5.00) WBC (10 9 /L) <10×10 3 221 (90.6) 23 (9.4) Reference group <0.001 ≥10×10 3 218 (77.6) 63 (22.4) 2.78 (1.69-4.72) Albumin ≥3.5mg/dL 397 (87.1) 59 (12.9) Reference group <0.001 <3.5mg/dL 42 (60.9) 27 (39.1) 4.33 (2.47-7.52) Operative type Elective 172 (85.1) 30 (14.9) Reference group <0.001 Emergency 267 (82.7) 56 (17.3) 1.20 (0.75-1.97) Wound class I and II 329 (90.1) 36 (9.9) Reference group <0.001 III and IV 110 (68.8) 50 (31.2) 4.15 (2.58-6.75) Anesthesia type Spinal 110 (84.0) 21 (16.0) Reference group 0.900 General 329 (83.5) 65 (16.5) 1.03 (0.61-1.81) Safety checklist used Yes 395 (83.9) 76 (16.1) Reference group 0.654 No 44 (81.5) 10 (18.5) 1.18 (0.54-2.36) Blood loss <200 ml 96 (94.1) 6 (5.9) Reference group 0.003 ≥200 ml 343 (81.1) 80 (18.9) 3.73 (1.71-9.83) Operation duration (min) Mean (SD) 72.5 (25.9) 96.5 (30.7) 1.03 (1.02-1.04) <0.001 Drain insertion No 15 (88.2) 2 (11.8) Reference group 0.603 Yes 424 (83.5) 84 (16.5) 1.49 (0.41-9.54) Hospital stays <5 days 177 (92.2) 15 (7.8) Reference group <0.001 ≥5 days 262 (78.7) 71 (21.3) 3.20 (1.82-5.96) Surgical site Large bowel 151 (83.0) 31 (17.0) Reference group 0.769 Small bowel and other GI sites 288 (84.0) 55 (16.0) 1.08 (0.66-1.73) NNIS index No risk 240 (96.0) 10 (4.0) Reference group Low risk 86 (76.8) 26 (23.2) 7.26 (3.46-16.37) <0.001 Moderate risk 87 (68.0) 41 (32.0) 11.31 (5.64-24.79) <0.001 High risk 26 (74.3) 9 (25.7) 8.31 (3.05-22.51) <0.001 ASA score Low (1 or 2) 322 (86.8) 49 (13.2) Reference group 0.003 High (3 or 4) 117 (76.0) 37 (24.0) 2.08 (1.29-3.34) Multivariate logistic regression revealed the following independent risk factors Illiteracy (OR: 40.31; 95% CI: 9.54-170.26), current smoking (OR: 21.15; 95% CI: 4.63-96.67), diabetes (OR: 5.07; 95% CI: 2.27-11.35), leukocytosis (OR: 2.62; 95% CI: 1.24-5.53), hypoalbuminemia (OR: 3.70; 95% CI: 1.35-10.16), contaminated and dirty wounds (OR: 6.51; 95% CI: 1.62-26.09), longer operative duration (OR: 1.02; 95% CI: 1.01-1.03), emergency operations (OR: 12.58; 95% CI: 2.91-54.30), and administering antibiotics before 1 hour of operation (OR: 3.01; 95% CI: 1.28-7.10) were independent factors for SSI (all p-value<0.05, Table 5 ). The prediction model’s total ROC curve was 0.946, which was much higher than the NNIS score (0.660) ( Figure 1 ). Table 5. Multivariate analysis of risk factors associated with surgical site infection. Predictor Estimate SE Z P value OR 95%CI Lower Upper Education level 3.6966 0.73508 5.0288 <0.001 40.31 9.54351 170.26 Khat chewing 0.6876 2.97657 0.2310 0.817 1.99 0.00582 679.66 Smoking 3.0518 0.77527 3.9365 <0.001 21.15 4.62903 96.67 Hypertension -0.8014 0.84596 -0.9473 0.343 0.45 0.08548 2.36 Diabetes 1.6240 0.41073 3.9539 <0.001 5.07 2.26816 11.35 Hair removal time 0.5350 0.41789 1.2802 0.200 1.70 0.75272 3.87 Temperature 0.2583 0.39358 0.6563 0.512 1.29 0.59864 2.80 leukocytosis 0.9643 0.38089 2.5316 0.011 2.62 1.24327 5.53 Hospital stays 0.2963 0.47340 0.6260 0.531 1.34 0.53180 3.40 Albumin 1.3094 0.51494 2.5429 0.011 3.70 1.35007 10.16 Wound class 1.8735 0.70827 2.6451 0.008 6.51 1.62461 26.09 Blood loss 0.6588 2.99194 0.2202 0.826 1.93 0.00549 680.54 Operation duration 0.0214 0.00644 3.3313 <0.001 1.02 1.00886 1.03 ASA score -0.2291 0.58612 -0.3909 0.696 0.79 0.25212 2.51 NNIS score -0.0705 0.85520 -0.0825 0.934 0.93 0.17435 4.98 Operative type 2.5323 0.74601 3.3944 <0.001 12.58 2.91575 54.30 Antibiotic time 1.1032 0.43687 2.5253 0.012 3.01 1.28013 7.10 Accuracy: 0.905; Specificity: 0.966; Sensitivity: 0.593; AUC: 0.946. Nagelkerke R square: 0.648 Significance of the model <0.001 Figure 1. The receiver operating characteristic curve of the prediction model compared with the National Nosocomial Infections Surveillance risk index in the validation cohort. Abbreviations: AUROC: Area under the receiver operating characteristic curve; NNIS: National Nosocomial Infections Surveillance. Discussion The improved access to healthcare, increased population age, and increased complexity of surgical interventions and patients’ conditions shed light on the importance of managing post-operative complications. Despite the precautions and the hygienic approach implemented to limit the incidence of SSI, it still represents one of the most common post-operative complications. Such infections result in an increased healthcare expenditure, and worsened mortality and morbidity. 10 This predicament can be especially disadvantageous for low-income nations, where providing healthcare is already a daunting task due to constrained resources, indigent communities, and elevated levels of antimicrobial resistance. 11 Among the 525 enrolled patients, the incidence of SSI within 30 days after surgery was 16.4%, which is in line with previous reports from developing countries, such as Saudi Arabia, with a rate of 16.3%. 14 However, earlier studies showed much higher rates of SSI affecting up to one-third of the patients in Yemen. 8 In contrast, more recent reports from Yemen have demonstrated a lower incidence of SSI, with a rate of 12.7% among patients who underwent gastrointestinal procedures. 8 Our findings, which showed a slightly higher rate of SSI, could be partially attributed to the larger number of complicated cases or complex oncological procedures performed at our tertiary teaching hospital. Several studies have been conducted to evaluate the link between putative risk variables and SSI in GI surgical operations. However, there is a large range of variation in the variables analyzed and the proportional effect of these factors on individual outcomes. To address this issue, we comprehensively studied the preoperative and operational risk variables in GI operations associated with the development of postoperative SSI. Hamza et al . and Lakoh et al . carried out similar investigations. 6 , 12 This study found that illiteracy, current smoking status, DM, leukocytosis, hypoalbuminemia, contaminated and dirty wounds, longer operation duration, emergency operations, and longer time between administering antibiotics and operation were predictors for the development of SSI. Most of the potential predictive factors included have been previously reported as risk factors in other studies with a variety of reports and different levels. 6 , 12 The relationship between age and SSI risk is complex and not well understood. While some studies have reported an increased rate of infection in older patients, others have observed a favorable trend with increasing age. For instance, Kaye et al . demonstrated a 1.2% decrease in SSI risk for each additional year after 65 years of age. 13 Nevertheless, these findings were demonstrated consistently, as a higher rate of SSI was observed in the older population. 14 , 15 Typically, with increasing age, there is an accumulated risk of developing comorbidities and immune dysfunction, which may lead to an increased likelihood of SSI. However, our study’s findings revealed no association between age and the development of SSI. This divergence may be attributed to variations in age categorization, as the majority of patients (67%) in this study were younger than 65 years. The present study reveals a significant association between the level of literacy and the incidence of SSI. Specifically, illiterate patients were 40 times more susceptible to SSIs than educated patients. These results are in accordance with previous research conducted by Mezemir et al . and Baker et al. 16 , 17 Notably, a high prevalence of limited health literacy among adults in our country may adversely impact health outcomes. For example, patients with limited health literacy may experience difficulty in comprehending complex health information, may exhibit non-compliance with postoperative instructions, and may not adequately prepare for surgery. These factors may increase the risk of SSIs and other adverse outcomes, highlighting the potential health inequality in providing care and education for illiterate patients. Therefore, it is critical to improve health literacy among patients, particularly those with limited education, to potentially reduce the incidence of SSIs and enhance surgical outcomes. This study did not find a significant association between unmodifiable risk factors, such as gender, BMI, residency, number of comorbidities (hypertension, history of malignancy, CRF, liver and lung diseases), perioperative blood transfusion, and SSIs in multivariate analysis. Although these social determinants are important factors that may contribute to patient outcomes, there is a lack of consensus on their association with SSI occurrence in the literature. For example, Marzoug et al. found that male sex and a greater number of comorbidities were associated with SSI occurrence. 18 Additionally, Li et al . reported that ascites, bleeding diathesis, history of lung disease, radiotherapy, chemotherapy, chronic steroid use, and weight loss were associated with SSI occurrence. 19 In contrast, Mezemir et al . did not find an association between gender, BMI, and SSI occurrence, which was similar to our study. 16 These discrepancies may be attributed to sample size and demographics variation across studies, as well as variations in the documentation and management of patient comorbidities. The use of more objective measures, such as preoperative laboratory and radiologic values, may provide a better understanding of the association between comorbidities and SSI occurrence. Distinctly, in this study, DM and hypoalbuminemia had 5- and 3.7 times higher chances of developing SSIs, respectively. This association was observed in prior studies, 11 , 20 as hyperglycemia has been shown to impair WBC functions, leading to decreased immunity. 21 On the other hand, reduced serum albumin levels are often associated with malnutrition or chronic wasting diseases. 11 However, the glucose levels were not available for the included patients and the albumin level was converted into categorical variables for a better presentation of the nomogram. Our study revealed that smoking was strongly associated with a 21-fold increased risk of developing SSIs compared to non-smokers. The vasoconstrictive and toxic effects of smoking are known to impede tissue oxygen delivery and hinder the healing process, thus contributing to the development of SSIs. These findings align with previous reports by Mawalla et al . and Billoro et al . 22 , 23 Regarding Khat ( Catha edulis ) chewing, its role in SSI occurrence remains uncertain. Our study observed a 1.99-fold increase in SSI occurrence among Khat chewers, although this association was not statistically significant. Currently, there is a lack of published studies specifically investigating the relationship between SSI and Khat chewing. However, Misha et al . found no association between Khat chewing and SSI occurrence in their regression analysis. 3 Nevertheless, Khat chewing has been linked to various gastric issues ( e.g. , intestinal obstruction, and gastritis). 24 Furthermore, long-term Khat consumption poses a risk of developing severe complications including hepatitis, hepatic fibrosis, and cirrhosis in advanced stages. 25 Future prospective and more inclusive studies are recommended to investigate this issue, particularly in our country where the traditional use of these plants is widespread. The settings of operation can significantly impact the development of SSI. Prior research has suggested that the degree of intraoperative wound contamination is indicative of SSI occurrence. 26 , 27 We found that contaminated and dirty wounds were 6.51 times more likely to develop SSI, which was consistent with other studies. 26 – 28 In this study, no statistically significant difference in SSI occurrence between colorectal procedures and other GI site procedures. However, most large-bowel SSIs were deep SSI types (8/31 in large bowel procedures vs., 3/25 in biliary and pancreatic procedures vs., 3/30 in small bowel procedures). According to data published by the National Healthcare Safety Network, rates of SSI following bile duct, liver, or pancreatic surgery are as high as 10 per 100 procedures. Rates of SSI following colon surgery are approximately 5 per 100 procedures, and rates of SSI following gallbladder surgery are 0.7 per 100 procedures. 29 Bozzay et al. study, the incisional SSI rates were higher following small bowel and gastrostomy closure procedures than for colorectal procedures and 66.1% of the cumulative incisional SSI burden from all procedures was attributable to 3 procedure groups (gastrostomy: 27.5%, small bowel: 22.9%, colorectal: 15.7%). 30 However, our findings were inconsistent with the literature documenting pancreatic and biliary leaks as independent risk factors for SSI occurrence. 27 This discrepancy could be attributed to the low number of cases involving biliary and pancreatic procedures, with most of them undergoing simple operations. Therefore, further prospective studies with a larger number of cases are necessary to clarify this issue. Our study also found that emergency operations were 12.58 times more likely to result in SSI, consistent with other studies. 6 , 11 In addition, leukocytosis was found to be a predictor for the development of SSI, which aligns with previous research. 31 Additionally, prolonged operation duration was recognized as an independent factor for SSI development in other studies, as it increases the risk of infection due to extensive surgical procedures and incisions, prolonged anesthesia, blood loss, and weaning antimicrobial prophylaxis concentration. 6 , 32 Furthermore, administering antibiotics one hour before operation has been reported as a predictor for SSI in previous studies. 23 , 33 In this study, it was observed that longer operation durations and administration of antibiotics more than one hour before the operation increased the likelihood of SSI by 1.02 times and 3.01 times, respectively. These findings are consistent with previous studies that showed the importance of re-dosing when this duration reaches the half-life of the administered antibiotic and guidelines recommend it. 23 , 32 In this study, the time for hair removal was not statistically significant in multivariate analysis. This was in line with a recently published systematic review by Tanner et al. who mentioned that hair removal with clippers or depilatory cream may reduce the risk of SSIs, but not fewer than shaving with a razor. Moderate-certainty evidence suggests clippers or creams may reduce SSIs and complications. Hair removal on the day of surgery may also reduce risk. 33 On the other hand, Zhang et al. reported that patients undergoing hair removal (the day of surgery or the night before surgery) had lower SSI incidence compared with those without hair removal. 34 In this study, we investigated the microorganisms responsible for SSIs and their susceptibility to commonly prescribed prophylactic antibiotics. We found that the most common organisms isolated from infected wounds were Gram-negative bacteria, with extended-spectrum β-lactamase-producing E. coli being the most prevalent. Mawalla et al . reported a different outcome compared to this finding, as their studies indicated a higher presence of Gram-positive bacteria, including Staphylococcus aureus. 22 In contrast, studies have reported similar findings to ours, demonstrating a higher occurrence of Gram-negative bacteria in infected abdominal wounds. 26 , 35 Furthermore, our findings revealed a high prevalence of multi-resistant pathogens in relation to commonly prescribed prophylactic antibiotics, which may serve as an explanation for the elevated rate of deep SSI observed in our study. Hence, there is a need to consider appropriate prophylactic antibiotics, especially for high-risk patients. Additionally, strict adherence to surgical site infection prevention techniques Such as disinfection and sterilization of medical and surgical tools to avoid the spread of infectious germs need to get more attention. Healthcare rules should specify whether cleaning, disinfection, or sterilization is required based on the item's intended usage. The NNIS risk index is a widely recognized framework for assessing and predicting the likelihood of SSI. 9 Within our study, two elements of the NNIS exhibited statistical significance (operation duration and wound class). However, upon conducting multivariate analysis, the overall NNIS model did not yield statistical significance. Moreover, when comparing the predictive accuracy, our developed model outperformed the NNIS model. Acutely, the performance of the NNIS model in this study showed poor predictive performance for the SSI occurrence as determined by the ROC curve. These results align with previous findings reported by Zhang et al . 11 Surgical site infections can be prevented by a variety of techniques, including improved preoperative surgical site preparation, good infection control management during procedures, careful adherence to prophylactic antibiotics administration, and a variety of preventive measures aimed at neutralizing the threat of bacterial, viral, and fungal contamination posed by operative staff, the operating room environment, and the patient's endogenous skin flora. Glucose-level control, improved oxygen supply, and normothermia maintenance are three new areas that have the potential to lower the incidence of SSIs even further. Continuous study into the biology of SSIs, as well as rigorous adherence to the use of evidence-based proven techniques to minimize SSIs, can help to further reduce the health and cost repercussions of SSIs. 6 , 12 Study limitations There are several limitations to consider in this study. First, the retrospective nature of the study may introduce an unintended bias to the study. In addition, it was conducted at a single tertiary teaching hospital, which may limit the generalizability of the findings to other healthcare settings. Furthermore, the study relied on clinical documentation to identify SSI, which could lead to underreporting or misclassification of cases. Moreover, the study focused on a specific geographic region, and the findings may not apply to other populations with different demographics or healthcare systems. Although the study took into account certain potential confounding variables ( e.g. , the use of prophylactic antibiotics), other potential confounding variables are difficult to assess with the retrospective nature of the study ( e.g. , surgical techniques and intra-operative maintenance of sterile technique, among others). Finally, the study did not explore long-term outcomes or evaluate the impact of interventions aimed at reducing surgical site infections. Based on our findings, further research needs to be validated in a large prospective cohort study with a long-term post-procedural follow up and the use of local coordinators may minimize these potential biases. Conclusions This study highlights significant predictors of SSI, including illiteracy, active smoking, DM, leukocytosis, hypoalbuminemia, contaminated and dirty wounds, longer operation duration, emergency operations, and extending antibiotic prophylaxis duration. Escherichia coli was the most common pathogen and had a high rate of multidrug-resistant strains. Identifying these risk factors can help surgeons adopt appropriate measures to reduce SSI and improve the quality of surgical care, especially in a resource-limited setting with no obvious and strict policy for reducing SSI. Ethical considerations Ethical approval was granted by the Ethics Research Committees of Ibb University [ID: IBBUNI.AC.YEM.2023.75, on 03/03/2023]. Data availability Underlying data Mendeley Data: Identification of Predictive Factors for Surgical Site Infections in Gastrointestinal Surgeries: A Retrospective Cross-Sectional Study in a Resource-Limited Setting, http://dx.doi.org/10.17632/hk75wrwr6n.1 . 36 Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). Acknowledgments The authors would like to thank the general manager of Al-Thora General Hospital and Al-Nassar Hospital, Ibb, Yemen, Dr. Abdulghani Ghabisha, for their editorial assistance. References 1. Utsumi M, Shimizu J, Miyamoto A, et al. : Age as an independent risk factor for surgical site infections in a large gastrointestinal surgery cohort in Japan. J. Hosp. Infect. 2010 Jul; 75 (3): 183–187. PubMed Abstract | Publisher Full Text 2. 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Hamza WS, Salama MF, Morsi SS, et al. : Benchmarking for surgical site infections among gastrointestinal surgeries and related risk factors: multicenter study in Kuwait. Infect. Drug Resist. 2018; 11 : 1373–1381. PubMed Abstract | Publisher Full Text | Free Full Text 7. Raja’a YA, Salam AR, Salih YA, et al. : Rate and risk factors of surgical site infections with antibiotic prophylaxis. Saudi Med. J. 2002 Jun; 23 (6): 672–674. PubMed Abstract 8. Nasser A, Zhang X, Yang L, et al. : Assessment of surgical site infections from signs & symptoms of the wound and associated factors in public hospitals of Hodeidah City, Yemen. J. Int. J. Appl. 2013; 3 (3): 101–110. 9. Sangsuwan T, Jamulitrat S, Watcharasin P: Risk adjustment performance between NNIS index and NHSN model for postoperative colorectal surgical site infection: A retrospective cohort study. Ann. Med. Surg (Lond). 2022 May; 77 : 103715. PubMed Abstract | Publisher Full Text | Free Full Text 10. 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Publisher Full Text Comments on this article Comments (0) Version 3 VERSION 3 PUBLISHED 23 Jun 2023 ADD YOUR COMMENT Comment Author details Author details 1 Department of General Surgery, School of Medicine, Ibb University of Medical Sciences, Ibb, Yemen 2 Department of Urology, School of Medicine, Ibb University of Medical Sciences, Ibb, Yemen 3 Department of Internal Medicine, Faculty of Medicine, Hadhramaut University, Hadhramau, Yemen 4 Department of General Surgery, School of Medicine, 21 September University, Sana'a, Yemen 5 Department of Gynaecology, School of Medicine, Jeblah University for Medical and Health Sciences, Ibb, Yemen Abdu Al-hajri Roles: Conceptualization, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Software Saif Ghabisha Roles: Conceptualization, Data Curation, Investigation, Software, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Faisal Ahmed Roles: Conceptualization, Data Curation, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Saleh Al-wageeh Roles: Data Curation, Investigation, Methodology, Resources, Software, Visualization Mohamed Badheeb Roles: Data Curation, Methodology, Software, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Qasem Alyhari Roles: Data Curation, Formal Analysis, Investigation, Supervision, Validation Abdulfattah Altam Roles: Data Curation, Funding Acquisition, Investigation, Supervision, Validation Afaf Alsharif Roles: Formal Analysis, Investigation, Methodology, Supervision, Writing – Original Draft Preparation Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (3) version 3 Revised Published: 30 May 2024, 12:733 https://doi.org/10.12688/f1000research.135681.3 version 2 Revised Published: 18 Jan 2024, 12:733 https://doi.org/10.12688/f1000research.135681.2 version 1 Published: 23 Jun 2023, 12:733 https://doi.org/10.12688/f1000research.135681.1 Copyright © 2024 Al-hajri A et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Al-hajri A, Ghabisha S, Ahmed F et al. Identification of predictive factors for surgical site infections in gastrointestinal surgeries: A retrospective cross-sectional study in a resource-limited setting [version 3; peer review: 1 approved, 2 approved with reservations] . F1000Research 2024, 12 :733 ( https://doi.org/10.12688/f1000research.135681.3 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 3 VERSION 3 PUBLISHED 30 May 2024 Revised Views 0 Cite How to cite this report: Calomino N. Reviewer Report For: Identification of predictive factors for surgical site infections in gastrointestinal surgeries: A retrospective cross-sectional study in a resource-limited setting [version 3; peer review: 1 approved, 2 approved with reservations] . F1000Research 2024, 12 :733 ( https://doi.org/10.5256/f1000research.167059.r314188 ) The direct URL for this report is: https://f1000research.com/articles/12-733/v3#referee-response-314188 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 28 Aug 2024 Natale Calomino , University of Siena, Siena, Italy Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.167059.r314188 The aim of the work is to investigate the possibility of predicting surgical site infection. The abstract induces the curiosity to read the article in its entirety. in the introduction we focus on the fact that surgical site infection is ... Continue reading READ ALL The aim of the work is to investigate the possibility of predicting surgical site infection. The abstract induces the curiosity to read the article in its entirety. in the introduction we focus on the fact that surgical site infection is nosocomial. This concept needs to be described better, in fact it is nosocomial because it happens in hospital, or it is nosocomial because the contaminating bacteria are of nosocomial origin, for example we can notice that in a smaller ward the patients have wounds infected by the same bacterial strains. We absolutely agree on the factors that induce infections. The study design and methods are well orchestrated with the right inclusion and exclusion criteria. We also agree on the approval of the ethics committee. We learn without having to add anything about the results. In the discussion we absolutely agree on what was said regarding the socio-economic factors and the clinical conditions with which patients present themselves in hospital. I liked what was said about hair removal, to this I would add the shower before each operation and antibiotic prophylaxis, in this regard I recommend an article already the subject of numerous citations [ref 1 ], to be cited in the bibliography. We agree on the conclusions. Great digression on limitations. English worth reviewing, good iconography, even if the images are a bit small. The bibliography is a good basis for the article. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes References 1. Marano L, Carbone L, Poto GE, Calomino N, et al.: Antimicrobial Prophylaxis Reduces the Rate of Surgical Site Infection in Upper Gastrointestinal Surgery: A Systematic Review. Antibiotics (Basel) . 2022; 11 (2). PubMed Abstract | Publisher Full Text Competing Interests: No competing interests were disclosed. Reviewer Expertise: generale surgery, oncological surgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Calomino N. Reviewer Report For: Identification of predictive factors for surgical site infections in gastrointestinal surgeries: A retrospective cross-sectional study in a resource-limited setting [version 3; peer review: 1 approved, 2 approved with reservations] . F1000Research 2024, 12 :733 ( https://doi.org/10.5256/f1000research.167059.r314188 ) The direct URL for this report is: https://f1000research.com/articles/12-733/v3#referee-response-314188 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Version 2 VERSION 2 PUBLISHED 18 Jan 2024 Revised Views 0 Cite How to cite this report: Sasmal PK. Reviewer Report For: Identification of predictive factors for surgical site infections in gastrointestinal surgeries: A retrospective cross-sectional study in a resource-limited setting [version 3; peer review: 1 approved, 2 approved with reservations] . F1000Research 2024, 12 :733 ( https://doi.org/10.5256/f1000research.161396.r258951 ) The direct URL for this report is: https://f1000research.com/articles/12-733/v2#referee-response-258951 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 26 Apr 2024 Prakash Kumar Sasmal , AIIMS, Bhubaneswar, India Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.161396.r258951 Dear authors, This retrospective study aims to determine prediction factors for surgical site infection in a developing country after gastrointestinal surgery. SSIs are very common and distressing not only to the patients but also to the surgeons. Time and ... Continue reading READ ALL Dear authors, This retrospective study aims to determine prediction factors for surgical site infection in a developing country after gastrointestinal surgery. SSIs are very common and distressing not only to the patients but also to the surgeons. Time and again, it is clear that SSIs after surgery are caused by several factors and not a single factor correction will ever decrease the rate. However, a few points need to be clarified to understand the readers better, as recall bias is more expected in a retrospective study. As multiple variables are taken to correlate only the associations, it becomes challenging to point out a particular cause to rectify. 1- As far as I can interpret in the study, the authors have put leucocytosis and high neutrophils as one of the factors for SSIs. Is leucocytosis the cause or effect of SSIs? 2- The prolonged hospital stays >5 days were the cause of SSIs or the effect of the infection, for which the patients were not discharged. 3- The Khat chewing, as mentioned in Table 5, has spelling errors. 4- The type of organ-specific SSIs in case of bowel, biliary and pancreatic surgery need to be specified whether there was a documented leak in those cases. Especially in pancreatic cases, whether preop stenting was done or not. 5- The organisms responsible need to be subclassified according to the bowel, biliary or pancreatic surgery, as the readers will benefit from knowing the common bacteria involved. 6- The authors have tried to correlate the incidence of SSIs in males and females. I do not think comparing the incidences of various genders is prudent, as it is a matter of chance. 7- The approach of surgery, whether open or laparoscopic, should be well mentioned as the details can be easily retrieved from the data. We cannot compare open surgery incidences of SSIs with laparoscopic surgery. 8- The common pathogens isolated were E coli and Enterococcus . The authors need to mention facts about the sterilisation and disinfection techniques used in your hospital to rule out a common source. 9- There is a repetition of the reference No 13 and 14. Please check it. 10- The authors need to put a few lines based on studies regarding steps to reduce SSIs overall in gastrointestinal procedures. Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Gastrointestinal and Metabolic surgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Sasmal PK. Reviewer Report For: Identification of predictive factors for surgical site infections in gastrointestinal surgeries: A retrospective cross-sectional study in a resource-limited setting [version 3; peer review: 1 approved, 2 approved with reservations] . F1000Research 2024, 12 :733 ( https://doi.org/10.5256/f1000research.161396.r258951 ) The direct URL for this report is: https://f1000research.com/articles/12-733/v2#referee-response-258951 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 28 Jun 2024 Faisal Ahmed , $usrAffiliation 28 Jun 2024 Author Response APPROVED WITH RESERVATIONS Dear authors, This retrospective study aims to determine prediction factors for surgical site infection in a developing country after gastrointestinal surgery. SSIs are very common and distressing ... Continue reading APPROVED WITH RESERVATIONS Dear authors, This retrospective study aims to determine prediction factors for surgical site infection in a developing country after gastrointestinal surgery. SSIs are very common and distressing not only to the patients but also to the surgeons. Time and again, it is clear that SSIs after surgery are caused by several factors, and not a single factor correction will ever decrease the rate. However, a few points need to be clarified to understand the readers better, as recall bias is more expected in a retrospective study. As multiple variables are taken to correlate only the associations, it becomes challenging to point out a particular cause to rectify. As far as I can interpret in the study, the authors have put leucocytosis and high neutrophils as one of the factors for SSIs. Is leucocytosis the cause or effect of SSIs? Answer: Thank you very much. Leukocytosis was a predictive factor for SSI occurrence and not the cause. The prolonged hospital stays >5 days were the cause of SSIs or the effect of the infection, for which the patients were not discharged. Answer: Thank you very much. Prolonged hospital stays >5 days were a predictive factor for SSI occurrence and not the cause. The Khat chewing, as mentioned in Table 5, has spelling errors. Answer: Thank you very much. It was revised as you mentioned. The type of organ-specific SSIs in case of bowel, biliary, and pancreatic surgery need to be specified whether there was a documented leak in those cases. Especially in pancreatic cases, whether preop stenting was done or not. Answer: Thank you very much. Unfortunately, the data on postoperative leaks is not available for all cases. a future study focused on SSI occurrence and specific postoperative complications in specific organs is planned. The organisms responsible need to be subclassified according to the bowel, biliary, or pancreatic surgery, as the readers will benefit from knowing the common bacteria involved. Answer: Thank you very much. It was revised and mentioned in Table 3. The authors have tried to correlate the incidence of SSIs in males and females. I do not think comparing the incidences of various genders is prudent, as it is a matter of chance. Answer: Thank you very much. This factor was not statistically significant. Additionally, we could not remove any collected factor without justification. The approach of surgery, whether open or laparoscopic, should be well mentioned as the details can be easily retrieved from the data. We cannot compare open surgery incidences of SSIs with laparoscopic surgery. Answer: Thank you very much. Unfortunately, we did not have laparoscopic equipment in our center. The common pathogens isolated were E coli and Enterococcus. The authors need to mention facts about the sterilization and disinfection techniques used in your hospital to rule out a common source. Answer: Thank you very much. We added a paragraph on this issue in the discussion section as you recommended in the microorganisms responsible for SSIs paragraph. The added section was " Additionally, strict adherence to surgical site infection prevention techniques Such as disinfection and sterilization of medical and surgical tools to avoid the spread of infectious germs need to get more attention. Healthcare rules should specify whether cleaning, disinfection, or sterilization is required based on the item's intended usage". There is a repetition of the reference No 13 and 14. Please check it. Answer: Thank you very much. The reference 13 was changed as you recommended. The authors need to put a few lines based on studies regarding steps to reduce SSIs overall in gastrointestinal procedures Answer: Thank you very much. We added a paragraph in the discussion section regarding this issue. The added section is " Surgical site infections can be prevented by a variety of techniques, including improved preoperative surgical site preparation, good infection control management during procedures, careful adherence to prophylactic antibiotics administration, and a variety of preventive measures aimed at neutralizing the threat of bacterial, viral, and fungal contamination posed by operative staff, the operating room environment, and the patient's endogenous skin flora. Glucose-level control, improved oxygen supply, and normothermia maintenance are three new areas that have the potential to lower the incidence of SSIs even further. Continuous study into the biology of SSIs, as well as rigorous adherence to the use of evidence-based proven techniques to minimize SSIs, can help to further reduce the health and cost repercussions of SSIs." Is the work clearly and accurately presented and does it cite the current literature? Partly Answer: Thank you very much. All mentioned comments were responded to and included in the revised manuscript. Is the study design appropriate and is the work technically sound? Partly Answer: Thank you very much. All mentioned comments were responded to and included in the revised manuscript. Are sufficient details of methods and analysis provided to allow replication by others? Yes Answer: Thank you very much. If applicable, is the statistical analysis and its interpretation appropriate? Yes Answer: Thank you very much. Are all the source data underlying the results available to ensure full reproducibility? Yes Answer: Thank you very much. Are the conclusions drawn adequately supported by the results? Yes Answer: Thank you very much. Competing Interests No competing interests were disclosed. Answer: Thank you very much. Reviewer Expertise Gastrointestinal and Metabolic surgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however, I have significant reservations, as outlined above. Answer: Thank you very much. APPROVED WITH RESERVATIONS Dear authors, This retrospective study aims to determine prediction factors for surgical site infection in a developing country after gastrointestinal surgery. SSIs are very common and distressing not only to the patients but also to the surgeons. Time and again, it is clear that SSIs after surgery are caused by several factors, and not a single factor correction will ever decrease the rate. However, a few points need to be clarified to understand the readers better, as recall bias is more expected in a retrospective study. As multiple variables are taken to correlate only the associations, it becomes challenging to point out a particular cause to rectify. As far as I can interpret in the study, the authors have put leucocytosis and high neutrophils as one of the factors for SSIs. Is leucocytosis the cause or effect of SSIs? Answer: Thank you very much. Leukocytosis was a predictive factor for SSI occurrence and not the cause. The prolonged hospital stays >5 days were the cause of SSIs or the effect of the infection, for which the patients were not discharged. Answer: Thank you very much. Prolonged hospital stays >5 days were a predictive factor for SSI occurrence and not the cause. The Khat chewing, as mentioned in Table 5, has spelling errors. Answer: Thank you very much. It was revised as you mentioned. The type of organ-specific SSIs in case of bowel, biliary, and pancreatic surgery need to be specified whether there was a documented leak in those cases. Especially in pancreatic cases, whether preop stenting was done or not. Answer: Thank you very much. Unfortunately, the data on postoperative leaks is not available for all cases. a future study focused on SSI occurrence and specific postoperative complications in specific organs is planned. The organisms responsible need to be subclassified according to the bowel, biliary, or pancreatic surgery, as the readers will benefit from knowing the common bacteria involved. Answer: Thank you very much. It was revised and mentioned in Table 3. The authors have tried to correlate the incidence of SSIs in males and females. I do not think comparing the incidences of various genders is prudent, as it is a matter of chance. Answer: Thank you very much. This factor was not statistically significant. Additionally, we could not remove any collected factor without justification. The approach of surgery, whether open or laparoscopic, should be well mentioned as the details can be easily retrieved from the data. We cannot compare open surgery incidences of SSIs with laparoscopic surgery. Answer: Thank you very much. Unfortunately, we did not have laparoscopic equipment in our center. The common pathogens isolated were E coli and Enterococcus. The authors need to mention facts about the sterilization and disinfection techniques used in your hospital to rule out a common source. Answer: Thank you very much. We added a paragraph on this issue in the discussion section as you recommended in the microorganisms responsible for SSIs paragraph. The added section was " Additionally, strict adherence to surgical site infection prevention techniques Such as disinfection and sterilization of medical and surgical tools to avoid the spread of infectious germs need to get more attention. Healthcare rules should specify whether cleaning, disinfection, or sterilization is required based on the item's intended usage". There is a repetition of the reference No 13 and 14. Please check it. Answer: Thank you very much. The reference 13 was changed as you recommended. The authors need to put a few lines based on studies regarding steps to reduce SSIs overall in gastrointestinal procedures Answer: Thank you very much. We added a paragraph in the discussion section regarding this issue. The added section is " Surgical site infections can be prevented by a variety of techniques, including improved preoperative surgical site preparation, good infection control management during procedures, careful adherence to prophylactic antibiotics administration, and a variety of preventive measures aimed at neutralizing the threat of bacterial, viral, and fungal contamination posed by operative staff, the operating room environment, and the patient's endogenous skin flora. Glucose-level control, improved oxygen supply, and normothermia maintenance are three new areas that have the potential to lower the incidence of SSIs even further. Continuous study into the biology of SSIs, as well as rigorous adherence to the use of evidence-based proven techniques to minimize SSIs, can help to further reduce the health and cost repercussions of SSIs." Is the work clearly and accurately presented and does it cite the current literature? Partly Answer: Thank you very much. All mentioned comments were responded to and included in the revised manuscript. Is the study design appropriate and is the work technically sound? Partly Answer: Thank you very much. All mentioned comments were responded to and included in the revised manuscript. Are sufficient details of methods and analysis provided to allow replication by others? Yes Answer: Thank you very much. If applicable, is the statistical analysis and its interpretation appropriate? Yes Answer: Thank you very much. Are all the source data underlying the results available to ensure full reproducibility? Yes Answer: Thank you very much. Are the conclusions drawn adequately supported by the results? Yes Answer: Thank you very much. Competing Interests No competing interests were disclosed. Answer: Thank you very much. Reviewer Expertise Gastrointestinal and Metabolic surgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however, I have significant reservations, as outlined above. Answer: Thank you very much. Competing Interests: none. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 28 Jun 2024 Faisal Ahmed , $usrAffiliation 28 Jun 2024 Author Response APPROVED WITH RESERVATIONS Dear authors, This retrospective study aims to determine prediction factors for surgical site infection in a developing country after gastrointestinal surgery. SSIs are very common and distressing ... Continue reading APPROVED WITH RESERVATIONS Dear authors, This retrospective study aims to determine prediction factors for surgical site infection in a developing country after gastrointestinal surgery. SSIs are very common and distressing not only to the patients but also to the surgeons. Time and again, it is clear that SSIs after surgery are caused by several factors, and not a single factor correction will ever decrease the rate. However, a few points need to be clarified to understand the readers better, as recall bias is more expected in a retrospective study. As multiple variables are taken to correlate only the associations, it becomes challenging to point out a particular cause to rectify. As far as I can interpret in the study, the authors have put leucocytosis and high neutrophils as one of the factors for SSIs. Is leucocytosis the cause or effect of SSIs? Answer: Thank you very much. Leukocytosis was a predictive factor for SSI occurrence and not the cause. The prolonged hospital stays >5 days were the cause of SSIs or the effect of the infection, for which the patients were not discharged. Answer: Thank you very much. Prolonged hospital stays >5 days were a predictive factor for SSI occurrence and not the cause. The Khat chewing, as mentioned in Table 5, has spelling errors. Answer: Thank you very much. It was revised as you mentioned. The type of organ-specific SSIs in case of bowel, biliary, and pancreatic surgery need to be specified whether there was a documented leak in those cases. Especially in pancreatic cases, whether preop stenting was done or not. Answer: Thank you very much. Unfortunately, the data on postoperative leaks is not available for all cases. a future study focused on SSI occurrence and specific postoperative complications in specific organs is planned. The organisms responsible need to be subclassified according to the bowel, biliary, or pancreatic surgery, as the readers will benefit from knowing the common bacteria involved. Answer: Thank you very much. It was revised and mentioned in Table 3. The authors have tried to correlate the incidence of SSIs in males and females. I do not think comparing the incidences of various genders is prudent, as it is a matter of chance. Answer: Thank you very much. This factor was not statistically significant. Additionally, we could not remove any collected factor without justification. The approach of surgery, whether open or laparoscopic, should be well mentioned as the details can be easily retrieved from the data. We cannot compare open surgery incidences of SSIs with laparoscopic surgery. Answer: Thank you very much. Unfortunately, we did not have laparoscopic equipment in our center. The common pathogens isolated were E coli and Enterococcus. The authors need to mention facts about the sterilization and disinfection techniques used in your hospital to rule out a common source. Answer: Thank you very much. We added a paragraph on this issue in the discussion section as you recommended in the microorganisms responsible for SSIs paragraph. The added section was " Additionally, strict adherence to surgical site infection prevention techniques Such as disinfection and sterilization of medical and surgical tools to avoid the spread of infectious germs need to get more attention. Healthcare rules should specify whether cleaning, disinfection, or sterilization is required based on the item's intended usage". There is a repetition of the reference No 13 and 14. Please check it. Answer: Thank you very much. The reference 13 was changed as you recommended. The authors need to put a few lines based on studies regarding steps to reduce SSIs overall in gastrointestinal procedures Answer: Thank you very much. We added a paragraph in the discussion section regarding this issue. The added section is " Surgical site infections can be prevented by a variety of techniques, including improved preoperative surgical site preparation, good infection control management during procedures, careful adherence to prophylactic antibiotics administration, and a variety of preventive measures aimed at neutralizing the threat of bacterial, viral, and fungal contamination posed by operative staff, the operating room environment, and the patient's endogenous skin flora. Glucose-level control, improved oxygen supply, and normothermia maintenance are three new areas that have the potential to lower the incidence of SSIs even further. Continuous study into the biology of SSIs, as well as rigorous adherence to the use of evidence-based proven techniques to minimize SSIs, can help to further reduce the health and cost repercussions of SSIs." Is the work clearly and accurately presented and does it cite the current literature? Partly Answer: Thank you very much. All mentioned comments were responded to and included in the revised manuscript. Is the study design appropriate and is the work technically sound? Partly Answer: Thank you very much. All mentioned comments were responded to and included in the revised manuscript. Are sufficient details of methods and analysis provided to allow replication by others? Yes Answer: Thank you very much. If applicable, is the statistical analysis and its interpretation appropriate? Yes Answer: Thank you very much. Are all the source data underlying the results available to ensure full reproducibility? Yes Answer: Thank you very much. Are the conclusions drawn adequately supported by the results? Yes Answer: Thank you very much. Competing Interests No competing interests were disclosed. Answer: Thank you very much. Reviewer Expertise Gastrointestinal and Metabolic surgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however, I have significant reservations, as outlined above. Answer: Thank you very much. APPROVED WITH RESERVATIONS Dear authors, This retrospective study aims to determine prediction factors for surgical site infection in a developing country after gastrointestinal surgery. SSIs are very common and distressing not only to the patients but also to the surgeons. Time and again, it is clear that SSIs after surgery are caused by several factors, and not a single factor correction will ever decrease the rate. However, a few points need to be clarified to understand the readers better, as recall bias is more expected in a retrospective study. As multiple variables are taken to correlate only the associations, it becomes challenging to point out a particular cause to rectify. As far as I can interpret in the study, the authors have put leucocytosis and high neutrophils as one of the factors for SSIs. Is leucocytosis the cause or effect of SSIs? Answer: Thank you very much. Leukocytosis was a predictive factor for SSI occurrence and not the cause. The prolonged hospital stays >5 days were the cause of SSIs or the effect of the infection, for which the patients were not discharged. Answer: Thank you very much. Prolonged hospital stays >5 days were a predictive factor for SSI occurrence and not the cause. The Khat chewing, as mentioned in Table 5, has spelling errors. Answer: Thank you very much. It was revised as you mentioned. The type of organ-specific SSIs in case of bowel, biliary, and pancreatic surgery need to be specified whether there was a documented leak in those cases. Especially in pancreatic cases, whether preop stenting was done or not. Answer: Thank you very much. Unfortunately, the data on postoperative leaks is not available for all cases. a future study focused on SSI occurrence and specific postoperative complications in specific organs is planned. The organisms responsible need to be subclassified according to the bowel, biliary, or pancreatic surgery, as the readers will benefit from knowing the common bacteria involved. Answer: Thank you very much. It was revised and mentioned in Table 3. The authors have tried to correlate the incidence of SSIs in males and females. I do not think comparing the incidences of various genders is prudent, as it is a matter of chance. Answer: Thank you very much. This factor was not statistically significant. Additionally, we could not remove any collected factor without justification. The approach of surgery, whether open or laparoscopic, should be well mentioned as the details can be easily retrieved from the data. We cannot compare open surgery incidences of SSIs with laparoscopic surgery. Answer: Thank you very much. Unfortunately, we did not have laparoscopic equipment in our center. The common pathogens isolated were E coli and Enterococcus. The authors need to mention facts about the sterilization and disinfection techniques used in your hospital to rule out a common source. Answer: Thank you very much. We added a paragraph on this issue in the discussion section as you recommended in the microorganisms responsible for SSIs paragraph. The added section was " Additionally, strict adherence to surgical site infection prevention techniques Such as disinfection and sterilization of medical and surgical tools to avoid the spread of infectious germs need to get more attention. Healthcare rules should specify whether cleaning, disinfection, or sterilization is required based on the item's intended usage". There is a repetition of the reference No 13 and 14. Please check it. Answer: Thank you very much. The reference 13 was changed as you recommended. The authors need to put a few lines based on studies regarding steps to reduce SSIs overall in gastrointestinal procedures Answer: Thank you very much. We added a paragraph in the discussion section regarding this issue. The added section is " Surgical site infections can be prevented by a variety of techniques, including improved preoperative surgical site preparation, good infection control management during procedures, careful adherence to prophylactic antibiotics administration, and a variety of preventive measures aimed at neutralizing the threat of bacterial, viral, and fungal contamination posed by operative staff, the operating room environment, and the patient's endogenous skin flora. Glucose-level control, improved oxygen supply, and normothermia maintenance are three new areas that have the potential to lower the incidence of SSIs even further. Continuous study into the biology of SSIs, as well as rigorous adherence to the use of evidence-based proven techniques to minimize SSIs, can help to further reduce the health and cost repercussions of SSIs." Is the work clearly and accurately presented and does it cite the current literature? Partly Answer: Thank you very much. All mentioned comments were responded to and included in the revised manuscript. Is the study design appropriate and is the work technically sound? Partly Answer: Thank you very much. All mentioned comments were responded to and included in the revised manuscript. Are sufficient details of methods and analysis provided to allow replication by others? Yes Answer: Thank you very much. If applicable, is the statistical analysis and its interpretation appropriate? Yes Answer: Thank you very much. Are all the source data underlying the results available to ensure full reproducibility? Yes Answer: Thank you very much. Are the conclusions drawn adequately supported by the results? Yes Answer: Thank you very much. Competing Interests No competing interests were disclosed. Answer: Thank you very much. Reviewer Expertise Gastrointestinal and Metabolic surgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however, I have significant reservations, as outlined above. Answer: Thank you very much. Competing Interests: none. Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Troillet N. Reviewer Report For: Identification of predictive factors for surgical site infections in gastrointestinal surgeries: A retrospective cross-sectional study in a resource-limited setting [version 3; peer review: 1 approved, 2 approved with reservations] . F1000Research 2024, 12 :733 ( https://doi.org/10.5256/f1000research.161396.r238885 ) The direct URL for this report is: https://f1000research.com/articles/12-733/v2#referee-response-238885 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 07 Feb 2024 Nicolas Troillet , Department for Infectious Diseases, Central Institution, Valais Hospital, Sion, Switzerland Approved VIEWS 0 https://doi.org/10.5256/f1000research.161396.r238885 No new comment. The article has been substantially improved by the authors' revision References 1. Al-hajri A, Ghabisha S, Ahmed F, Al-wageeh S, et al.: Identification of predictive factors for surgical site infections in gastrointestinal surgeries: A retrospective cross-sectional study in ... Continue reading READ ALL No new comment. The article has been substantially improved by the authors' revision References 1. Al-hajri A, Ghabisha S, Ahmed F, Al-wageeh S, et al.: Identification of predictive factors for surgical site infections in gastrointestinal surgeries: A retrospective cross-sectional study in a resource-limited setting. F1000Research . 2024; 12 . Publisher Full Text Competing Interests: No competing interests were disclosed. Reviewer Expertise: Healthcare associated infections, clinical infectious diseases. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Troillet N. Reviewer Report For: Identification of predictive factors for surgical site infections in gastrointestinal surgeries: A retrospective cross-sectional study in a resource-limited setting [version 3; peer review: 1 approved, 2 approved with reservations] . F1000Research 2024, 12 :733 ( https://doi.org/10.5256/f1000research.161396.r238885 ) The direct URL for this report is: https://f1000research.com/articles/12-733/v2#referee-response-238885 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 23 May 2024 Faisal Ahmed , Urology Research Center, Al-Thora General Hospital, Department of Urology, School of Medicine, Ibb University of Medical Sciences, Ibb, Yemen 23 May 2024 Author Response Dear Reviewer Thank you very much for your effort in acting on my revised manuscript. Competing Interests: No competing interests were disclosed. Dear Reviewer Thank you very much for your effort in acting on my revised manuscript. Dear Reviewer Thank you very much for your effort in acting on my revised manuscript. Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 23 May 2024 Faisal Ahmed , Urology Research Center, Al-Thora General Hospital, Department of Urology, School of Medicine, Ibb University of Medical Sciences, Ibb, Yemen 23 May 2024 Author Response Dear Reviewer Thank you very much for your effort in acting on my revised manuscript. Competing Interests: No competing interests were disclosed. Dear Reviewer Thank you very much for your effort in acting on my revised manuscript. Dear Reviewer Thank you very much for your effort in acting on my revised manuscript. Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Version 1 VERSION 1 PUBLISHED 23 Jun 2023 Views 0 Cite How to cite this report: Troillet N. Reviewer Report For: Identification of predictive factors for surgical site infections in gastrointestinal surgeries: A retrospective cross-sectional study in a resource-limited setting [version 3; peer review: 1 approved, 2 approved with reservations] . F1000Research 2024, 12 :733 ( https://doi.org/10.5256/f1000research.148812.r192612 ) The direct URL for this report is: https://f1000research.com/articles/12-733/v1#referee-response-192612 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 25 Aug 2023 Nicolas Troillet , Department for Infectious Diseases, Central Institution, Valais Hospital, Sion, Switzerland Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.148812.r192612 This is an interesting and well written study aiming at determining a prediction rule for surgical site infection after digestive surgery in a developing country. It gathered a substantial number of parameters for univariate and multivariable analysis in order to ... Continue reading READ ALL This is an interesting and well written study aiming at determining a prediction rule for surgical site infection after digestive surgery in a developing country. It gathered a substantial number of parameters for univariate and multivariable analysis in order to develop a prediction model that performs better than the classical NNIS index. The authors might want to consider the comments and questions below and revise their paper accordingly. The abstract mentions a SSI rate of 15% (79/525), whereas the results section and the discussion state 16.4% (86/525). The abstract states that the majority of SSI were superficial but detailed results on the depth of SSI (superficial, deep, organ/space) are not provided in the results section. These data would be interesting by type of surgery. The inclusion criteria state that all eligible patients between June 2015 and October 2022 were included, reaching 525 patients in about 7 years. Knowing the number of patients excluded would be of interest. Precisions on how SSI were detected would be of interest. Was the diagnosis made by surgeons or infection control personnel? Were all the patients followed-up after discharge? If yes, by systematic visits? All SSI were microbiologically documented. Was it because samples were taken from all patients with a clinically diagnosed SSI or because positive lab results were used to identify patients with SSI? Operations are grouped in four categories (small bowel, large bowel, biliary, and pancreatic) in the description of the population analyzed. More details would be interesting to know which operations were included in these four categories, e.g. how many cholecystectomies were included in biliary surgery? Were appendectomies included in large bowel surgery or only colon surgery? Did large bowel surgery include rectal surgery? These operations are then grouped in two categories (small bowel and others) in the statistical analyses. Although small bowel surgery represents the highest number of included operations, grouping large bowel surgery with biliary surgery appears counterintuitive, especially if cholecystectomies, which are much less at risk than colon surgery, represent the majority of biliary surgery. Could the results have been different and reached statistical significance if the comparison had been made between large bowel and others rather than between small bowel and others? Some continuous variables such as age, hospital stay, BMI or temperature were stratified into binomial variables for the statistical analyses. Did it imply a loss of power for detecting risk factors and perhaps better determine a cut-off for the prediction? This applies particularly for age which could have been considered as an ordinal variable and stratified first in ten-year categories. The timing of shaving was found significant but shaving is not recommended by international guidelines and may constitute a risk factor for SSI (cf. for example reference 2 in the present paper). Is shaving systematically done in this hospital? Avoiding it accordingly with guidelines could constitute a simple mean for decreasing SSI rates that could be mentioned in the discussion. It is stated that variables with a p value <0.2 in univariate analysis were fitted for logistic regression but “antibiotic timing” and “operative type”, which had both higher p values in univariate analysis (p=0.454 and p=0.506, respectively, as presented in table 4) are nevertheless part of the multivariable model (table 5). More details would be useful for a better understanding. Do all the operations performed in digestive surgery in this hospital correspond to open surgery? Since operations done with a laparoscope have been shown to be less at risk for SSI, information would be of interest about it in the methods and in the discussion. It is stated that “pathogens linked with SSI were identified from all SSI patient wounds”. The total number of pathogens in table 3 amounts to 86 for 86 patients. This would mean that only one pathogen was identified from every patient with SSI. Were no patients suffering from a polymicrobial SSI detected (which is relatively frequent in colon surgery)? Were no other pathogens identified than the seven presented in table 3? For example, Enterobacter spp. streptococci or Candida spp.? More details would be of interest on resistance patterns of the isolated bacteria: proportion of ESBL producers in E. coli and Klebsiella respectively, presence or not of carbapenemase-producing Enterobacteriaceae, resistance profile of Pseudomonas aeruginosa, resistance to vancomycine in enterococci. Mentioning the substances usually administered for antibiotic prophylaxis in these operations would help better realizing the magnitude of the problem of antibiotic resistance in this setting. Were only the significant variables in the multivariable analysis used for calculating the performance of the model for predicting SSI? Please specify. Discussion, paragraph 6. Mentioning whether glucose levels were not available for the included patients together with albumin levels or were available but not analyzed would be of interest since, irrespective of a history of diabetes, this could constitute, as stated, a risk factor for SSI. Discussion, paragraph 9. The following sentence is hard to understand: “Furthermore, our study revealed that the prevalence of SSI in large, pancreatic, and biliary surgeries was lower than in intestinal procedures; although this association was not statistically significant.” Does “large” mean large bowel? Then “intestinal” might mean small bowel. Please clarify. In addition, please refer to comments 5 and 6 above for possible modifications in the discussion about this result. Discussion, paragraph 10. It is stated that a long duration may induce weaning prophylactic antibiotic concentration. Studies have shown the importance of re-dosing when this duration reach the half-life of the administered antibiotic and guidelines recommend it. This could be mentioned here and cited as a mean to lower SSI rates. Discussion, paragraph 11. Please refer to comments 11, 12, and 13 above and possibly take them into account for extending the discussion about antibiotic resistance in this paragraph. Limitations, 3 rd sentence. Does “clinical identification” mean that no radiological or laboratory markers were used to help for the diagnosis of SSI? If yes, this should be specified in the methods. If not, underreporting might be due to interobserver variability if persons with different backgrounds did it (e.g. surgeons, infectious diseases physicians, infection control nurses). Limitations, 4 th sentence. Internal and external validation on other datasets or prospectively should be mentioned as a mean to consolidate these findings. Typos. Table 1: “During 1 hour of operation” instead of “During 1 house of operation”. Table 3: “Pseudomonas aeruginosa” instead of “Pseudomonas aerugisa”. Terminology. The same words should be used through the different tables (e.g. “surgical status” in table 1 instead of “operative type” in tables 4 and 5). Consider using “operation duration” instead of “operative time”. References 13 and 14 are identical. Reference 18 corresponds to a correction: please mention the original publication. (The source data are available but the corresponding file could not be opened.) Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Healthcare associated infections, clinical infectious diseases. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Troillet N. Reviewer Report For: Identification of predictive factors for surgical site infections in gastrointestinal surgeries: A retrospective cross-sectional study in a resource-limited setting [version 3; peer review: 1 approved, 2 approved with reservations] . F1000Research 2024, 12 :733 ( https://doi.org/10.5256/f1000research.148812.r192612 ) The direct URL for this report is: https://f1000research.com/articles/12-733/v1#referee-response-192612 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 23 May 2024 Faisal Ahmed , Urology Research Center, Al-Thora General Hospital, Department of Urology, School of Medicine, Ibb University of Medical Sciences, Ibb, Yemen 23 May 2024 Author Response Dear reviewer Thank you very much for reading and reviewing my manuscript. This is an interesting and well-written study aiming at determining a prediction rule for surgical site infection after ... Continue reading Dear reviewer Thank you very much for reading and reviewing my manuscript. This is an interesting and well-written study aiming at determining a prediction rule for surgical site infection after digestive surgery in a developing country. It gathered a substantial number of parameters for univariate and multivariable analysis to develop a prediction model that performs better than the classical NNIS index. The authors might want to consider the comments and questions below and revise their paper accordingly. The abstract mentions an SSI rate of 15% (79/525), whereas the results section and the discussion state 16.4%. (86/525) Answer: Thank you. We apologize for this mistake. The exact number was revised in the abstract section. The abstract states that the majority of SSI were superficial but detailed results on the depth of SSI (superficial, deep, organ/space) are not provided in the results section. These data would be interesting by type of surgery. Answer: Thank you. The SSI type was added to the result section (Causative Pathogens section). The inclusion criteria state that all eligible patients between June 2015 and October 2022 were included, reaching 525 patients in about 7 years. Knowing the number of patients excluded would be of interest. Answer: Thank you. Unfortunately, the total number of patients was not accurately calculated. For that, we avoided mentioning the total patient numbers. Precisions on how SSIs were detected would be of interest. Was the diagnosis made by surgeons and infection control personnel? Were all the patients followed up after discharge? If yes, by systematic visits? All SSIs were microbiologically documented. Was it because samples were taken from all patients with a clinically diagnosed SSI or because positive lab results were used to identify patients with SSI? Answer: Thank you. Regarding infection control personnel, it was corrected. Regarding patients followed up: yes. As they were operated, it is usually to have a regular follow-up. Additionally, we mentioned that they underwent systematic visits. Regarding microbiology documentation, all patients had culture and we mentioned it in the data collection section. The main causes of sample collection are the patient symptoms and the SSI suspected. Operations are grouped into four categories (small bowel, large bowel, biliary, and pancreatic) in the description of the population analyzed. More details would be interesting to know which operations were included in these four categories, e.g. how many cholecystectomies were included in biliary surgery? Were appendectomies included in large bowel surgery or only colon surgery? Did large bowel surgery include rectal surgery? Answer: Thank you. We did not collect the data regarding These operations are then grouped into two categories (small bowel and others) in the statistical analyses. Although small bowel surgery represents the highest number of included operations, grouping large bowel surgery with biliary surgery appears counterintuitive, especially if cholecystectomies, which are much less at risk than colon surgery, represent the majority of biliary surgery. Could the results have been different and reached statistical significance if the comparison had been made between Large bowel and others rather than between small bowel and others? Answer: Thank you. We revised it as you mentioned. However, it was not statistically significant as we mentioned in table 4. Some continuous variables such as age, hospital stay, BMI or temperature were stratified into binomial variables for the statistical analyses. Did it imply a loss of power for detecting risk factors and perhaps better determine a cut-off for the prediction? This applies particularly for age which could have been considered as an ordinal variable and stratified first in ten-year categories. Answer: Thank you. All the continuous variables were converted into categorical variables for a better presentation of the nomogram. This statement was mentioned. The timing of shaving was found significant but shaving is not recommended by international guidelines and may constitute a risk factor for SSI (cf. for example reference 2 in the present paper). Is shaving systematically done in this hospital? Avoiding it according with guidelines could constitute a simple means for decreasing SSI rates that could be mentioned in the discussion. Answer: Thank you. This item was revised to be Hair removal. We mentioned this issue in the discussion section. It is stated that variables with a p value <0.2 in univariate analysis were fitted for logistic regression but “antibiotic timing” and “operative type”, which had both higher p values in univariate analysis (p=0.454 and p=0.506, respectively, as presented in table 4) are nevertheless part of the multivariable model (table 5). More details would be useful for a better understanding. Answer: Thank you. To better understand, we revised the Statistical analysis section. 10. Do all the operations performed in digestive surgery in this hospital correspond to open surgery? Since operations done with a laparoscope have been shown to be less at risk for SSI, information would be of interest about it in the methods and in the discussion. Answer: Thank you. Unfortunately, the laparoscopic equipment is not available in our hospital. For that, we avoided mentioning the laparoscopic procedures. 11. It is stated that “pathogens linked with SSI were identified from all SSI patient wounds”. The total number of pathogens in table 3 amounts to 86 for 86 patients. This would mean that only one pathogen was identified from every patient with SSI. Were no patients suffering from a polymicrobial SSI detected (which is relatively frequent in colon surgery)? Were no other pathogens identified than the seven presented in Table 3? For example, Enterobacter spp. streptococci or Candida spp.? Answer: Thank you. This was the result reported by the laboratory. 12. More details would be of interest on resistance patterns of the isolated bacteria: proportion of ESBL producers in E. coli and Klebsiella respectively, presence or not of carbapenemase-producing Enterobacteriaceae, resistance profile of Pseudomonas aeruginosa, resistance to vancomycin in enterococci. Answer: Thank you. We did not collect the data regarding the antibiotic sensitivity or resistance. 13. Mentioning the substances usually administered for antibiotic prophylaxis in these operations would help better realize the magnitude of the problem of antibiotic resistance in this setting. Answer: Thank you. it was mentioned in the data collection section. 14. Were only the significant variables in the multivariable analysis used for calculating the performance of the model for predicting SSI? Please specify . Answer: Thank you. To better understand, we revised the Statistical analysis section. 15. Discussion, paragraph 6. Mentioning whether glucose levels were not available for the included patients together with albumin levels or were available but not analyzed would be of interest since, irrespective of a history of diabetes, this could constitute, as stated, a risk factor for SSI. Answer: Thank you. We mentioned this issue in the discussion section. 16. Discussion, paragraph 9. The following sentence is hard to understand: “Furthermore, our study revealed that the prevalence of SSI in large, pancreatic, and biliary surgeries was lower than in intestinal procedures; although this association was not statistically significant.” Does “large” mean large bowel? Then “intestinal” might mean small bowel. Please clarify. In addition, please refer to comments 5 and 6 above for possible modifications in the discussion about this result. Answer: Thank you. It was revised as you mentioned. 17. Discussion, paragraph 10. It is stated that a long duration may induce weaning prophylactic antibiotic concentration. Studies have shown the importance of re-dosing when this duration reaches the half-life of the administered antibiotic and guidelines recommend it. This could be mentioned here and cited as a means to lower SSI rates. Answer: Thank you. It was added as you mentioned. 18. Discussion, paragraph 11. Please refer to comments 11, 12, and 13 above and possibly take them into account for extending the discussion about antibiotic resistance in this paragraph. Answer: Thank you. We did not collect the data regarding the antibiotic sensitivity or resistance. 19. Limitations, 3rd sentence. Does “clinical identification” mean that no radiological or laboratory markers were used to help with the diagnosis of SSI? If yes, this should be specified in the methods. If not, underreporting might be due to interobserver variability if persons with different backgrounds did it (e.g. surgeons, infectious diseases physicians, infection control nurses). Answer: Thank you. The word clinical was removed. 20. Limitations, 4th sentence. Internal and external validation on other datasets or prospectively should be mentioned as a mean to consolidate these findings. Answer: Thank you. We added this issue as you recommended. 21. Typos. Table 1: “During 1 hour of operation” instead of “During 1 house of operation”. Table 3: “Pseudomonas aeruginosa” instead of “Pseudomonas aerugisa”. Answer: Thank you. It was revised through the manuscript. 22. Terminology. The same words should be used through the different tables (e.g. “surgical status” in Table 1 instead of “operative type” in Tables 4 and 5). Consider using “operation duration” instead of “operative time”. Answer: Thank you. It was revised as you mentioned. 23. References 13 and 14 are identical. Reference 18 corresponds to a correction: please mention the original publication. Answer: Thank you. All references were rechecked and corrected The source data are available but the corresponding file could not be opened. Answer: Thank you. The revised dates are available at this address. https://data.mendeley.com/datasets/hk75wrwr6n/2 Is the work clearly and accurately presented and does it cite the current literature? Yes Answer: Thank you. Is the study design appropriate and is the work technically sound? Yes Answer: Thank you. Are sufficient details of methods and analysis provided to allow replication by others? Partly Answer: Thank you. If applicable, is the statistical analysis and its interpretation appropriate? Partly Answer: Thank you. Are all the source data underlying the results available to ensure full reproducibility? Yes Answer: Thank you. Are the conclusions drawn adequately supported by the results? Yes Answer: Thank you. Competing Interests No competing interests were disclosed. Answer: Thank you. Reviewer Expertise Healthcare associated infections, clinical infectious diseases. Answer: Thank you. Dear reviewer Thank you very much for reading and reviewing my manuscript. This is an interesting and well-written study aiming at determining a prediction rule for surgical site infection after digestive surgery in a developing country. It gathered a substantial number of parameters for univariate and multivariable analysis to develop a prediction model that performs better than the classical NNIS index. The authors might want to consider the comments and questions below and revise their paper accordingly. The abstract mentions an SSI rate of 15% (79/525), whereas the results section and the discussion state 16.4%. (86/525) Answer: Thank you. We apologize for this mistake. The exact number was revised in the abstract section. The abstract states that the majority of SSI were superficial but detailed results on the depth of SSI (superficial, deep, organ/space) are not provided in the results section. These data would be interesting by type of surgery. Answer: Thank you. The SSI type was added to the result section (Causative Pathogens section). The inclusion criteria state that all eligible patients between June 2015 and October 2022 were included, reaching 525 patients in about 7 years. Knowing the number of patients excluded would be of interest. Answer: Thank you. Unfortunately, the total number of patients was not accurately calculated. For that, we avoided mentioning the total patient numbers. Precisions on how SSIs were detected would be of interest. Was the diagnosis made by surgeons and infection control personnel? Were all the patients followed up after discharge? If yes, by systematic visits? All SSIs were microbiologically documented. Was it because samples were taken from all patients with a clinically diagnosed SSI or because positive lab results were used to identify patients with SSI? Answer: Thank you. Regarding infection control personnel, it was corrected. Regarding patients followed up: yes. As they were operated, it is usually to have a regular follow-up. Additionally, we mentioned that they underwent systematic visits. Regarding microbiology documentation, all patients had culture and we mentioned it in the data collection section. The main causes of sample collection are the patient symptoms and the SSI suspected. Operations are grouped into four categories (small bowel, large bowel, biliary, and pancreatic) in the description of the population analyzed. More details would be interesting to know which operations were included in these four categories, e.g. how many cholecystectomies were included in biliary surgery? Were appendectomies included in large bowel surgery or only colon surgery? Did large bowel surgery include rectal surgery? Answer: Thank you. We did not collect the data regarding These operations are then grouped into two categories (small bowel and others) in the statistical analyses. Although small bowel surgery represents the highest number of included operations, grouping large bowel surgery with biliary surgery appears counterintuitive, especially if cholecystectomies, which are much less at risk than colon surgery, represent the majority of biliary surgery. Could the results have been different and reached statistical significance if the comparison had been made between Large bowel and others rather than between small bowel and others? Answer: Thank you. We revised it as you mentioned. However, it was not statistically significant as we mentioned in table 4. Some continuous variables such as age, hospital stay, BMI or temperature were stratified into binomial variables for the statistical analyses. Did it imply a loss of power for detecting risk factors and perhaps better determine a cut-off for the prediction? This applies particularly for age which could have been considered as an ordinal variable and stratified first in ten-year categories. Answer: Thank you. All the continuous variables were converted into categorical variables for a better presentation of the nomogram. This statement was mentioned. The timing of shaving was found significant but shaving is not recommended by international guidelines and may constitute a risk factor for SSI (cf. for example reference 2 in the present paper). Is shaving systematically done in this hospital? Avoiding it according with guidelines could constitute a simple means for decreasing SSI rates that could be mentioned in the discussion. Answer: Thank you. This item was revised to be Hair removal. We mentioned this issue in the discussion section. It is stated that variables with a p value <0.2 in univariate analysis were fitted for logistic regression but “antibiotic timing” and “operative type”, which had both higher p values in univariate analysis (p=0.454 and p=0.506, respectively, as presented in table 4) are nevertheless part of the multivariable model (table 5). More details would be useful for a better understanding. Answer: Thank you. To better understand, we revised the Statistical analysis section. 10. Do all the operations performed in digestive surgery in this hospital correspond to open surgery? Since operations done with a laparoscope have been shown to be less at risk for SSI, information would be of interest about it in the methods and in the discussion. Answer: Thank you. Unfortunately, the laparoscopic equipment is not available in our hospital. For that, we avoided mentioning the laparoscopic procedures. 11. It is stated that “pathogens linked with SSI were identified from all SSI patient wounds”. The total number of pathogens in table 3 amounts to 86 for 86 patients. This would mean that only one pathogen was identified from every patient with SSI. Were no patients suffering from a polymicrobial SSI detected (which is relatively frequent in colon surgery)? Were no other pathogens identified than the seven presented in Table 3? For example, Enterobacter spp. streptococci or Candida spp.? Answer: Thank you. This was the result reported by the laboratory. 12. More details would be of interest on resistance patterns of the isolated bacteria: proportion of ESBL producers in E. coli and Klebsiella respectively, presence or not of carbapenemase-producing Enterobacteriaceae, resistance profile of Pseudomonas aeruginosa, resistance to vancomycin in enterococci. Answer: Thank you. We did not collect the data regarding the antibiotic sensitivity or resistance. 13. Mentioning the substances usually administered for antibiotic prophylaxis in these operations would help better realize the magnitude of the problem of antibiotic resistance in this setting. Answer: Thank you. it was mentioned in the data collection section. 14. Were only the significant variables in the multivariable analysis used for calculating the performance of the model for predicting SSI? Please specify . Answer: Thank you. To better understand, we revised the Statistical analysis section. 15. Discussion, paragraph 6. Mentioning whether glucose levels were not available for the included patients together with albumin levels or were available but not analyzed would be of interest since, irrespective of a history of diabetes, this could constitute, as stated, a risk factor for SSI. Answer: Thank you. We mentioned this issue in the discussion section. 16. Discussion, paragraph 9. The following sentence is hard to understand: “Furthermore, our study revealed that the prevalence of SSI in large, pancreatic, and biliary surgeries was lower than in intestinal procedures; although this association was not statistically significant.” Does “large” mean large bowel? Then “intestinal” might mean small bowel. Please clarify. In addition, please refer to comments 5 and 6 above for possible modifications in the discussion about this result. Answer: Thank you. It was revised as you mentioned. 17. Discussion, paragraph 10. It is stated that a long duration may induce weaning prophylactic antibiotic concentration. Studies have shown the importance of re-dosing when this duration reaches the half-life of the administered antibiotic and guidelines recommend it. This could be mentioned here and cited as a means to lower SSI rates. Answer: Thank you. It was added as you mentioned. 18. Discussion, paragraph 11. Please refer to comments 11, 12, and 13 above and possibly take them into account for extending the discussion about antibiotic resistance in this paragraph. Answer: Thank you. We did not collect the data regarding the antibiotic sensitivity or resistance. 19. Limitations, 3rd sentence. Does “clinical identification” mean that no radiological or laboratory markers were used to help with the diagnosis of SSI? If yes, this should be specified in the methods. If not, underreporting might be due to interobserver variability if persons with different backgrounds did it (e.g. surgeons, infectious diseases physicians, infection control nurses). Answer: Thank you. The word clinical was removed. 20. Limitations, 4th sentence. Internal and external validation on other datasets or prospectively should be mentioned as a mean to consolidate these findings. Answer: Thank you. We added this issue as you recommended. 21. Typos. Table 1: “During 1 hour of operation” instead of “During 1 house of operation”. Table 3: “Pseudomonas aeruginosa” instead of “Pseudomonas aerugisa”. Answer: Thank you. It was revised through the manuscript. 22. Terminology. The same words should be used through the different tables (e.g. “surgical status” in Table 1 instead of “operative type” in Tables 4 and 5). Consider using “operation duration” instead of “operative time”. Answer: Thank you. It was revised as you mentioned. 23. References 13 and 14 are identical. Reference 18 corresponds to a correction: please mention the original publication. Answer: Thank you. All references were rechecked and corrected The source data are available but the corresponding file could not be opened. Answer: Thank you. The revised dates are available at this address. https://data.mendeley.com/datasets/hk75wrwr6n/2 Is the work clearly and accurately presented and does it cite the current literature? Yes Answer: Thank you. Is the study design appropriate and is the work technically sound? Yes Answer: Thank you. Are sufficient details of methods and analysis provided to allow replication by others? Partly Answer: Thank you. If applicable, is the statistical analysis and its interpretation appropriate? Partly Answer: Thank you. Are all the source data underlying the results available to ensure full reproducibility? Yes Answer: Thank you. Are the conclusions drawn adequately supported by the results? Yes Answer: Thank you. Competing Interests No competing interests were disclosed. Answer: Thank you. Reviewer Expertise Healthcare associated infections, clinical infectious diseases. Answer: Thank you. Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 23 May 2024 Faisal Ahmed , Urology Research Center, Al-Thora General Hospital, Department of Urology, School of Medicine, Ibb University of Medical Sciences, Ibb, Yemen 23 May 2024 Author Response Dear reviewer Thank you very much for reading and reviewing my manuscript. This is an interesting and well-written study aiming at determining a prediction rule for surgical site infection after ... Continue reading Dear reviewer Thank you very much for reading and reviewing my manuscript. This is an interesting and well-written study aiming at determining a prediction rule for surgical site infection after digestive surgery in a developing country. It gathered a substantial number of parameters for univariate and multivariable analysis to develop a prediction model that performs better than the classical NNIS index. The authors might want to consider the comments and questions below and revise their paper accordingly. The abstract mentions an SSI rate of 15% (79/525), whereas the results section and the discussion state 16.4%. (86/525) Answer: Thank you. We apologize for this mistake. The exact number was revised in the abstract section. The abstract states that the majority of SSI were superficial but detailed results on the depth of SSI (superficial, deep, organ/space) are not provided in the results section. These data would be interesting by type of surgery. Answer: Thank you. The SSI type was added to the result section (Causative Pathogens section). The inclusion criteria state that all eligible patients between June 2015 and October 2022 were included, reaching 525 patients in about 7 years. Knowing the number of patients excluded would be of interest. Answer: Thank you. Unfortunately, the total number of patients was not accurately calculated. For that, we avoided mentioning the total patient numbers. Precisions on how SSIs were detected would be of interest. Was the diagnosis made by surgeons and infection control personnel? Were all the patients followed up after discharge? If yes, by systematic visits? All SSIs were microbiologically documented. Was it because samples were taken from all patients with a clinically diagnosed SSI or because positive lab results were used to identify patients with SSI? Answer: Thank you. Regarding infection control personnel, it was corrected. Regarding patients followed up: yes. As they were operated, it is usually to have a regular follow-up. Additionally, we mentioned that they underwent systematic visits. Regarding microbiology documentation, all patients had culture and we mentioned it in the data collection section. The main causes of sample collection are the patient symptoms and the SSI suspected. Operations are grouped into four categories (small bowel, large bowel, biliary, and pancreatic) in the description of the population analyzed. More details would be interesting to know which operations were included in these four categories, e.g. how many cholecystectomies were included in biliary surgery? Were appendectomies included in large bowel surgery or only colon surgery? Did large bowel surgery include rectal surgery? Answer: Thank you. We did not collect the data regarding These operations are then grouped into two categories (small bowel and others) in the statistical analyses. Although small bowel surgery represents the highest number of included operations, grouping large bowel surgery with biliary surgery appears counterintuitive, especially if cholecystectomies, which are much less at risk than colon surgery, represent the majority of biliary surgery. Could the results have been different and reached statistical significance if the comparison had been made between Large bowel and others rather than between small bowel and others? Answer: Thank you. We revised it as you mentioned. However, it was not statistically significant as we mentioned in table 4. Some continuous variables such as age, hospital stay, BMI or temperature were stratified into binomial variables for the statistical analyses. Did it imply a loss of power for detecting risk factors and perhaps better determine a cut-off for the prediction? This applies particularly for age which could have been considered as an ordinal variable and stratified first in ten-year categories. Answer: Thank you. All the continuous variables were converted into categorical variables for a better presentation of the nomogram. This statement was mentioned. The timing of shaving was found significant but shaving is not recommended by international guidelines and may constitute a risk factor for SSI (cf. for example reference 2 in the present paper). Is shaving systematically done in this hospital? Avoiding it according with guidelines could constitute a simple means for decreasing SSI rates that could be mentioned in the discussion. Answer: Thank you. This item was revised to be Hair removal. We mentioned this issue in the discussion section. It is stated that variables with a p value <0.2 in univariate analysis were fitted for logistic regression but “antibiotic timing” and “operative type”, which had both higher p values in univariate analysis (p=0.454 and p=0.506, respectively, as presented in table 4) are nevertheless part of the multivariable model (table 5). More details would be useful for a better understanding. Answer: Thank you. To better understand, we revised the Statistical analysis section. 10. Do all the operations performed in digestive surgery in this hospital correspond to open surgery? Since operations done with a laparoscope have been shown to be less at risk for SSI, information would be of interest about it in the methods and in the discussion. Answer: Thank you. Unfortunately, the laparoscopic equipment is not available in our hospital. For that, we avoided mentioning the laparoscopic procedures. 11. It is stated that “pathogens linked with SSI were identified from all SSI patient wounds”. The total number of pathogens in table 3 amounts to 86 for 86 patients. This would mean that only one pathogen was identified from every patient with SSI. Were no patients suffering from a polymicrobial SSI detected (which is relatively frequent in colon surgery)? Were no other pathogens identified than the seven presented in Table 3? For example, Enterobacter spp. streptococci or Candida spp.? Answer: Thank you. This was the result reported by the laboratory. 12. More details would be of interest on resistance patterns of the isolated bacteria: proportion of ESBL producers in E. coli and Klebsiella respectively, presence or not of carbapenemase-producing Enterobacteriaceae, resistance profile of Pseudomonas aeruginosa, resistance to vancomycin in enterococci. Answer: Thank you. We did not collect the data regarding the antibiotic sensitivity or resistance. 13. Mentioning the substances usually administered for antibiotic prophylaxis in these operations would help better realize the magnitude of the problem of antibiotic resistance in this setting. Answer: Thank you. it was mentioned in the data collection section. 14. Were only the significant variables in the multivariable analysis used for calculating the performance of the model for predicting SSI? Please specify . Answer: Thank you. To better understand, we revised the Statistical analysis section. 15. Discussion, paragraph 6. Mentioning whether glucose levels were not available for the included patients together with albumin levels or were available but not analyzed would be of interest since, irrespective of a history of diabetes, this could constitute, as stated, a risk factor for SSI. Answer: Thank you. We mentioned this issue in the discussion section. 16. Discussion, paragraph 9. The following sentence is hard to understand: “Furthermore, our study revealed that the prevalence of SSI in large, pancreatic, and biliary surgeries was lower than in intestinal procedures; although this association was not statistically significant.” Does “large” mean large bowel? Then “intestinal” might mean small bowel. Please clarify. In addition, please refer to comments 5 and 6 above for possible modifications in the discussion about this result. Answer: Thank you. It was revised as you mentioned. 17. Discussion, paragraph 10. It is stated that a long duration may induce weaning prophylactic antibiotic concentration. Studies have shown the importance of re-dosing when this duration reaches the half-life of the administered antibiotic and guidelines recommend it. This could be mentioned here and cited as a means to lower SSI rates. Answer: Thank you. It was added as you mentioned. 18. Discussion, paragraph 11. Please refer to comments 11, 12, and 13 above and possibly take them into account for extending the discussion about antibiotic resistance in this paragraph. Answer: Thank you. We did not collect the data regarding the antibiotic sensitivity or resistance. 19. Limitations, 3rd sentence. Does “clinical identification” mean that no radiological or laboratory markers were used to help with the diagnosis of SSI? If yes, this should be specified in the methods. If not, underreporting might be due to interobserver variability if persons with different backgrounds did it (e.g. surgeons, infectious diseases physicians, infection control nurses). Answer: Thank you. The word clinical was removed. 20. Limitations, 4th sentence. Internal and external validation on other datasets or prospectively should be mentioned as a mean to consolidate these findings. Answer: Thank you. We added this issue as you recommended. 21. Typos. Table 1: “During 1 hour of operation” instead of “During 1 house of operation”. Table 3: “Pseudomonas aeruginosa” instead of “Pseudomonas aerugisa”. Answer: Thank you. It was revised through the manuscript. 22. Terminology. The same words should be used through the different tables (e.g. “surgical status” in Table 1 instead of “operative type” in Tables 4 and 5). Consider using “operation duration” instead of “operative time”. Answer: Thank you. It was revised as you mentioned. 23. References 13 and 14 are identical. Reference 18 corresponds to a correction: please mention the original publication. Answer: Thank you. All references were rechecked and corrected The source data are available but the corresponding file could not be opened. Answer: Thank you. The revised dates are available at this address. https://data.mendeley.com/datasets/hk75wrwr6n/2 Is the work clearly and accurately presented and does it cite the current literature? Yes Answer: Thank you. Is the study design appropriate and is the work technically sound? Yes Answer: Thank you. Are sufficient details of methods and analysis provided to allow replication by others? Partly Answer: Thank you. If applicable, is the statistical analysis and its interpretation appropriate? Partly Answer: Thank you. Are all the source data underlying the results available to ensure full reproducibility? Yes Answer: Thank you. Are the conclusions drawn adequately supported by the results? Yes Answer: Thank you. Competing Interests No competing interests were disclosed. Answer: Thank you. Reviewer Expertise Healthcare associated infections, clinical infectious diseases. Answer: Thank you. Dear reviewer Thank you very much for reading and reviewing my manuscript. This is an interesting and well-written study aiming at determining a prediction rule for surgical site infection after digestive surgery in a developing country. It gathered a substantial number of parameters for univariate and multivariable analysis to develop a prediction model that performs better than the classical NNIS index. The authors might want to consider the comments and questions below and revise their paper accordingly. The abstract mentions an SSI rate of 15% (79/525), whereas the results section and the discussion state 16.4%. (86/525) Answer: Thank you. We apologize for this mistake. The exact number was revised in the abstract section. The abstract states that the majority of SSI were superficial but detailed results on the depth of SSI (superficial, deep, organ/space) are not provided in the results section. These data would be interesting by type of surgery. Answer: Thank you. The SSI type was added to the result section (Causative Pathogens section). The inclusion criteria state that all eligible patients between June 2015 and October 2022 were included, reaching 525 patients in about 7 years. Knowing the number of patients excluded would be of interest. Answer: Thank you. Unfortunately, the total number of patients was not accurately calculated. For that, we avoided mentioning the total patient numbers. Precisions on how SSIs were detected would be of interest. Was the diagnosis made by surgeons and infection control personnel? Were all the patients followed up after discharge? If yes, by systematic visits? All SSIs were microbiologically documented. Was it because samples were taken from all patients with a clinically diagnosed SSI or because positive lab results were used to identify patients with SSI? Answer: Thank you. Regarding infection control personnel, it was corrected. Regarding patients followed up: yes. As they were operated, it is usually to have a regular follow-up. Additionally, we mentioned that they underwent systematic visits. Regarding microbiology documentation, all patients had culture and we mentioned it in the data collection section. The main causes of sample collection are the patient symptoms and the SSI suspected. Operations are grouped into four categories (small bowel, large bowel, biliary, and pancreatic) in the description of the population analyzed. More details would be interesting to know which operations were included in these four categories, e.g. how many cholecystectomies were included in biliary surgery? Were appendectomies included in large bowel surgery or only colon surgery? Did large bowel surgery include rectal surgery? Answer: Thank you. We did not collect the data regarding These operations are then grouped into two categories (small bowel and others) in the statistical analyses. Although small bowel surgery represents the highest number of included operations, grouping large bowel surgery with biliary surgery appears counterintuitive, especially if cholecystectomies, which are much less at risk than colon surgery, represent the majority of biliary surgery. Could the results have been different and reached statistical significance if the comparison had been made between Large bowel and others rather than between small bowel and others? Answer: Thank you. We revised it as you mentioned. However, it was not statistically significant as we mentioned in table 4. Some continuous variables such as age, hospital stay, BMI or temperature were stratified into binomial variables for the statistical analyses. Did it imply a loss of power for detecting risk factors and perhaps better determine a cut-off for the prediction? This applies particularly for age which could have been considered as an ordinal variable and stratified first in ten-year categories. Answer: Thank you. All the continuous variables were converted into categorical variables for a better presentation of the nomogram. This statement was mentioned. The timing of shaving was found significant but shaving is not recommended by international guidelines and may constitute a risk factor for SSI (cf. for example reference 2 in the present paper). Is shaving systematically done in this hospital? Avoiding it according with guidelines could constitute a simple means for decreasing SSI rates that could be mentioned in the discussion. Answer: Thank you. This item was revised to be Hair removal. We mentioned this issue in the discussion section. It is stated that variables with a p value <0.2 in univariate analysis were fitted for logistic regression but “antibiotic timing” and “operative type”, which had both higher p values in univariate analysis (p=0.454 and p=0.506, respectively, as presented in table 4) are nevertheless part of the multivariable model (table 5). More details would be useful for a better understanding. Answer: Thank you. To better understand, we revised the Statistical analysis section. 10. Do all the operations performed in digestive surgery in this hospital correspond to open surgery? Since operations done with a laparoscope have been shown to be less at risk for SSI, information would be of interest about it in the methods and in the discussion. Answer: Thank you. Unfortunately, the laparoscopic equipment is not available in our hospital. For that, we avoided mentioning the laparoscopic procedures. 11. It is stated that “pathogens linked with SSI were identified from all SSI patient wounds”. The total number of pathogens in table 3 amounts to 86 for 86 patients. This would mean that only one pathogen was identified from every patient with SSI. Were no patients suffering from a polymicrobial SSI detected (which is relatively frequent in colon surgery)? Were no other pathogens identified than the seven presented in Table 3? For example, Enterobacter spp. streptococci or Candida spp.? Answer: Thank you. This was the result reported by the laboratory. 12. More details would be of interest on resistance patterns of the isolated bacteria: proportion of ESBL producers in E. coli and Klebsiella respectively, presence or not of carbapenemase-producing Enterobacteriaceae, resistance profile of Pseudomonas aeruginosa, resistance to vancomycin in enterococci. Answer: Thank you. We did not collect the data regarding the antibiotic sensitivity or resistance. 13. Mentioning the substances usually administered for antibiotic prophylaxis in these operations would help better realize the magnitude of the problem of antibiotic resistance in this setting. Answer: Thank you. it was mentioned in the data collection section. 14. Were only the significant variables in the multivariable analysis used for calculating the performance of the model for predicting SSI? Please specify . Answer: Thank you. To better understand, we revised the Statistical analysis section. 15. Discussion, paragraph 6. Mentioning whether glucose levels were not available for the included patients together with albumin levels or were available but not analyzed would be of interest since, irrespective of a history of diabetes, this could constitute, as stated, a risk factor for SSI. Answer: Thank you. We mentioned this issue in the discussion section. 16. Discussion, paragraph 9. The following sentence is hard to understand: “Furthermore, our study revealed that the prevalence of SSI in large, pancreatic, and biliary surgeries was lower than in intestinal procedures; although this association was not statistically significant.” Does “large” mean large bowel? Then “intestinal” might mean small bowel. Please clarify. In addition, please refer to comments 5 and 6 above for possible modifications in the discussion about this result. Answer: Thank you. It was revised as you mentioned. 17. Discussion, paragraph 10. It is stated that a long duration may induce weaning prophylactic antibiotic concentration. Studies have shown the importance of re-dosing when this duration reaches the half-life of the administered antibiotic and guidelines recommend it. This could be mentioned here and cited as a means to lower SSI rates. Answer: Thank you. It was added as you mentioned. 18. Discussion, paragraph 11. Please refer to comments 11, 12, and 13 above and possibly take them into account for extending the discussion about antibiotic resistance in this paragraph. Answer: Thank you. We did not collect the data regarding the antibiotic sensitivity or resistance. 19. Limitations, 3rd sentence. Does “clinical identification” mean that no radiological or laboratory markers were used to help with the diagnosis of SSI? If yes, this should be specified in the methods. If not, underreporting might be due to interobserver variability if persons with different backgrounds did it (e.g. surgeons, infectious diseases physicians, infection control nurses). Answer: Thank you. The word clinical was removed. 20. Limitations, 4th sentence. Internal and external validation on other datasets or prospectively should be mentioned as a mean to consolidate these findings. Answer: Thank you. We added this issue as you recommended. 21. Typos. Table 1: “During 1 hour of operation” instead of “During 1 house of operation”. Table 3: “Pseudomonas aeruginosa” instead of “Pseudomonas aerugisa”. Answer: Thank you. It was revised through the manuscript. 22. Terminology. The same words should be used through the different tables (e.g. “surgical status” in Table 1 instead of “operative type” in Tables 4 and 5). Consider using “operation duration” instead of “operative time”. Answer: Thank you. It was revised as you mentioned. 23. References 13 and 14 are identical. Reference 18 corresponds to a correction: please mention the original publication. Answer: Thank you. All references were rechecked and corrected The source data are available but the corresponding file could not be opened. Answer: Thank you. The revised dates are available at this address. https://data.mendeley.com/datasets/hk75wrwr6n/2 Is the work clearly and accurately presented and does it cite the current literature? Yes Answer: Thank you. Is the study design appropriate and is the work technically sound? Yes Answer: Thank you. Are sufficient details of methods and analysis provided to allow replication by others? Partly Answer: Thank you. If applicable, is the statistical analysis and its interpretation appropriate? Partly Answer: Thank you. Are all the source data underlying the results available to ensure full reproducibility? Yes Answer: Thank you. Are the conclusions drawn adequately supported by the results? Yes Answer: Thank you. Competing Interests No competing interests were disclosed. Answer: Thank you. Reviewer Expertise Healthcare associated infections, clinical infectious diseases. Answer: Thank you. Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 3 VERSION 3 PUBLISHED 23 Jun 2023 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 3 Version 3 (revision) 30 May 24 read Version 2 (revision) 18 Jan 24 read read Version 1 23 Jun 23 read Nicolas Troillet , Valais Hospital, Sion, Switzerland Prakash Kumar Sasmal , AIIMS, Bhubaneswar, India Natale Calomino , University of Siena, Siena, Italy Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Calomino N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 28 Aug 2024 | for Version 3 Natale Calomino , University of Siena, Siena, Italy 0 Views copyright © 2024 Calomino N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The aim of the work is to investigate the possibility of predicting surgical site infection. The abstract induces the curiosity to read the article in its entirety. in the introduction we focus on the fact that surgical site infection is nosocomial. This concept needs to be described better, in fact it is nosocomial because it happens in hospital, or it is nosocomial because the contaminating bacteria are of nosocomial origin, for example we can notice that in a smaller ward the patients have wounds infected by the same bacterial strains. We absolutely agree on the factors that induce infections. The study design and methods are well orchestrated with the right inclusion and exclusion criteria. We also agree on the approval of the ethics committee. We learn without having to add anything about the results. In the discussion we absolutely agree on what was said regarding the socio-economic factors and the clinical conditions with which patients present themselves in hospital. I liked what was said about hair removal, to this I would add the shower before each operation and antibiotic prophylaxis, in this regard I recommend an article already the subject of numerous citations [ref 1 ], to be cited in the bibliography. We agree on the conclusions. Great digression on limitations. English worth reviewing, good iconography, even if the images are a bit small. The bibliography is a good basis for the article. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes References 1. Marano L, Carbone L, Poto GE, Calomino N, et al.: Antimicrobial Prophylaxis Reduces the Rate of Surgical Site Infection in Upper Gastrointestinal Surgery: A Systematic Review. Antibiotics (Basel) . 2022; 11 (2). PubMed Abstract | Publisher Full Text Competing Interests No competing interests were disclosed. Reviewer Expertise generale surgery, oncological surgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Calomino N. Peer Review Report For: Identification of predictive factors for surgical site infections in gastrointestinal surgeries: A retrospective cross-sectional study in a resource-limited setting [version 3; peer review: 1 approved, 2 approved with reservations] . F1000Research 2024, 12 :733 ( https://doi.org/10.5256/f1000research.167059.r314188) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/12-733/v3#referee-response-314188 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Sasmal P. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 26 Apr 2024 | for Version 2 Prakash Kumar Sasmal , AIIMS, Bhubaneswar, India 0 Views copyright © 2024 Sasmal P. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Dear authors, This retrospective study aims to determine prediction factors for surgical site infection in a developing country after gastrointestinal surgery. SSIs are very common and distressing not only to the patients but also to the surgeons. Time and again, it is clear that SSIs after surgery are caused by several factors and not a single factor correction will ever decrease the rate. However, a few points need to be clarified to understand the readers better, as recall bias is more expected in a retrospective study. As multiple variables are taken to correlate only the associations, it becomes challenging to point out a particular cause to rectify. 1- As far as I can interpret in the study, the authors have put leucocytosis and high neutrophils as one of the factors for SSIs. Is leucocytosis the cause or effect of SSIs? 2- The prolonged hospital stays >5 days were the cause of SSIs or the effect of the infection, for which the patients were not discharged. 3- The Khat chewing, as mentioned in Table 5, has spelling errors. 4- The type of organ-specific SSIs in case of bowel, biliary and pancreatic surgery need to be specified whether there was a documented leak in those cases. Especially in pancreatic cases, whether preop stenting was done or not. 5- The organisms responsible need to be subclassified according to the bowel, biliary or pancreatic surgery, as the readers will benefit from knowing the common bacteria involved. 6- The authors have tried to correlate the incidence of SSIs in males and females. I do not think comparing the incidences of various genders is prudent, as it is a matter of chance. 7- The approach of surgery, whether open or laparoscopic, should be well mentioned as the details can be easily retrieved from the data. We cannot compare open surgery incidences of SSIs with laparoscopic surgery. 8- The common pathogens isolated were E coli and Enterococcus . The authors need to mention facts about the sterilisation and disinfection techniques used in your hospital to rule out a common source. 9- There is a repetition of the reference No 13 and 14. Please check it. 10- The authors need to put a few lines based on studies regarding steps to reduce SSIs overall in gastrointestinal procedures. Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Gastrointestinal and Metabolic surgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 28 Jun 2024 Faisal Ahmed, APPROVED WITH RESERVATIONS Dear authors, This retrospective study aims to determine prediction factors for surgical site infection in a developing country after gastrointestinal surgery. SSIs are very common and distressing not only to the patients but also to the surgeons. Time and again, it is clear that SSIs after surgery are caused by several factors, and not a single factor correction will ever decrease the rate. However, a few points need to be clarified to understand the readers better, as recall bias is more expected in a retrospective study. As multiple variables are taken to correlate only the associations, it becomes challenging to point out a particular cause to rectify. As far as I can interpret in the study, the authors have put leucocytosis and high neutrophils as one of the factors for SSIs. Is leucocytosis the cause or effect of SSIs? Answer: Thank you very much. Leukocytosis was a predictive factor for SSI occurrence and not the cause. The prolonged hospital stays >5 days were the cause of SSIs or the effect of the infection, for which the patients were not discharged. Answer: Thank you very much. Prolonged hospital stays >5 days were a predictive factor for SSI occurrence and not the cause. The Khat chewing, as mentioned in Table 5, has spelling errors. Answer: Thank you very much. It was revised as you mentioned. The type of organ-specific SSIs in case of bowel, biliary, and pancreatic surgery need to be specified whether there was a documented leak in those cases. Especially in pancreatic cases, whether preop stenting was done or not. Answer: Thank you very much. Unfortunately, the data on postoperative leaks is not available for all cases. a future study focused on SSI occurrence and specific postoperative complications in specific organs is planned. The organisms responsible need to be subclassified according to the bowel, biliary, or pancreatic surgery, as the readers will benefit from knowing the common bacteria involved. Answer: Thank you very much. It was revised and mentioned in Table 3. The authors have tried to correlate the incidence of SSIs in males and females. I do not think comparing the incidences of various genders is prudent, as it is a matter of chance. Answer: Thank you very much. This factor was not statistically significant. Additionally, we could not remove any collected factor without justification. The approach of surgery, whether open or laparoscopic, should be well mentioned as the details can be easily retrieved from the data. We cannot compare open surgery incidences of SSIs with laparoscopic surgery. Answer: Thank you very much. Unfortunately, we did not have laparoscopic equipment in our center. The common pathogens isolated were E coli and Enterococcus. The authors need to mention facts about the sterilization and disinfection techniques used in your hospital to rule out a common source. Answer: Thank you very much. We added a paragraph on this issue in the discussion section as you recommended in the microorganisms responsible for SSIs paragraph. The added section was " Additionally, strict adherence to surgical site infection prevention techniques Such as disinfection and sterilization of medical and surgical tools to avoid the spread of infectious germs need to get more attention. Healthcare rules should specify whether cleaning, disinfection, or sterilization is required based on the item's intended usage". There is a repetition of the reference No 13 and 14. Please check it. Answer: Thank you very much. The reference 13 was changed as you recommended. The authors need to put a few lines based on studies regarding steps to reduce SSIs overall in gastrointestinal procedures Answer: Thank you very much. We added a paragraph in the discussion section regarding this issue. The added section is " Surgical site infections can be prevented by a variety of techniques, including improved preoperative surgical site preparation, good infection control management during procedures, careful adherence to prophylactic antibiotics administration, and a variety of preventive measures aimed at neutralizing the threat of bacterial, viral, and fungal contamination posed by operative staff, the operating room environment, and the patient's endogenous skin flora. Glucose-level control, improved oxygen supply, and normothermia maintenance are three new areas that have the potential to lower the incidence of SSIs even further. Continuous study into the biology of SSIs, as well as rigorous adherence to the use of evidence-based proven techniques to minimize SSIs, can help to further reduce the health and cost repercussions of SSIs." Is the work clearly and accurately presented and does it cite the current literature? Partly Answer: Thank you very much. All mentioned comments were responded to and included in the revised manuscript. Is the study design appropriate and is the work technically sound? Partly Answer: Thank you very much. All mentioned comments were responded to and included in the revised manuscript. Are sufficient details of methods and analysis provided to allow replication by others? Yes Answer: Thank you very much. If applicable, is the statistical analysis and its interpretation appropriate? Yes Answer: Thank you very much. Are all the source data underlying the results available to ensure full reproducibility? Yes Answer: Thank you very much. Are the conclusions drawn adequately supported by the results? Yes Answer: Thank you very much. Competing Interests No competing interests were disclosed. Answer: Thank you very much. Reviewer Expertise Gastrointestinal and Metabolic surgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however, I have significant reservations, as outlined above. Answer: Thank you very much. View more View less Competing Interests none. reply Respond Report a concern Sasmal PK. Peer Review Report For: Identification of predictive factors for surgical site infections in gastrointestinal surgeries: A retrospective cross-sectional study in a resource-limited setting [version 3; peer review: 1 approved, 2 approved with reservations] . F1000Research 2024, 12 :733 ( https://doi.org/10.5256/f1000research.161396.r258951) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/12-733/v2#referee-response-258951 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Troillet N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 07 Feb 2024 | for Version 2 Nicolas Troillet , Department for Infectious Diseases, Central Institution, Valais Hospital, Sion, Switzerland 0 Views copyright © 2024 Troillet N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions No new comment. The article has been substantially improved by the authors' revision References 1. Al-hajri A, Ghabisha S, Ahmed F, Al-wageeh S, et al.: Identification of predictive factors for surgical site infections in gastrointestinal surgeries: A retrospective cross-sectional study in a resource-limited setting. F1000Research . 2024; 12 . Publisher Full Text Competing Interests No competing interests were disclosed. Reviewer Expertise Healthcare associated infections, clinical infectious diseases. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (1) Author Response 23 May 2024 Faisal Ahmed, Urology Research Center, Al-Thora General Hospital, Department of Urology, School of Medicine, Ibb University of Medical Sciences, Ibb, Yemen Dear Reviewer Thank you very much for your effort in acting on my revised manuscript. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Troillet N. Peer Review Report For: Identification of predictive factors for surgical site infections in gastrointestinal surgeries: A retrospective cross-sectional study in a resource-limited setting [version 3; peer review: 1 approved, 2 approved with reservations] . F1000Research 2024, 12 :733 ( https://doi.org/10.5256/f1000research.161396.r238885) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/12-733/v2#referee-response-238885 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2023 Troillet N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 25 Aug 2023 | for Version 1 Nicolas Troillet , Department for Infectious Diseases, Central Institution, Valais Hospital, Sion, Switzerland 0 Views copyright © 2023 Troillet N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This is an interesting and well written study aiming at determining a prediction rule for surgical site infection after digestive surgery in a developing country. It gathered a substantial number of parameters for univariate and multivariable analysis in order to develop a prediction model that performs better than the classical NNIS index. The authors might want to consider the comments and questions below and revise their paper accordingly. The abstract mentions a SSI rate of 15% (79/525), whereas the results section and the discussion state 16.4% (86/525). The abstract states that the majority of SSI were superficial but detailed results on the depth of SSI (superficial, deep, organ/space) are not provided in the results section. These data would be interesting by type of surgery. The inclusion criteria state that all eligible patients between June 2015 and October 2022 were included, reaching 525 patients in about 7 years. Knowing the number of patients excluded would be of interest. Precisions on how SSI were detected would be of interest. Was the diagnosis made by surgeons or infection control personnel? Were all the patients followed-up after discharge? If yes, by systematic visits? All SSI were microbiologically documented. Was it because samples were taken from all patients with a clinically diagnosed SSI or because positive lab results were used to identify patients with SSI? Operations are grouped in four categories (small bowel, large bowel, biliary, and pancreatic) in the description of the population analyzed. More details would be interesting to know which operations were included in these four categories, e.g. how many cholecystectomies were included in biliary surgery? Were appendectomies included in large bowel surgery or only colon surgery? Did large bowel surgery include rectal surgery? These operations are then grouped in two categories (small bowel and others) in the statistical analyses. Although small bowel surgery represents the highest number of included operations, grouping large bowel surgery with biliary surgery appears counterintuitive, especially if cholecystectomies, which are much less at risk than colon surgery, represent the majority of biliary surgery. Could the results have been different and reached statistical significance if the comparison had been made between large bowel and others rather than between small bowel and others? Some continuous variables such as age, hospital stay, BMI or temperature were stratified into binomial variables for the statistical analyses. Did it imply a loss of power for detecting risk factors and perhaps better determine a cut-off for the prediction? This applies particularly for age which could have been considered as an ordinal variable and stratified first in ten-year categories. The timing of shaving was found significant but shaving is not recommended by international guidelines and may constitute a risk factor for SSI (cf. for example reference 2 in the present paper). Is shaving systematically done in this hospital? Avoiding it accordingly with guidelines could constitute a simple mean for decreasing SSI rates that could be mentioned in the discussion. It is stated that variables with a p value <0.2 in univariate analysis were fitted for logistic regression but “antibiotic timing” and “operative type”, which had both higher p values in univariate analysis (p=0.454 and p=0.506, respectively, as presented in table 4) are nevertheless part of the multivariable model (table 5). More details would be useful for a better understanding. Do all the operations performed in digestive surgery in this hospital correspond to open surgery? Since operations done with a laparoscope have been shown to be less at risk for SSI, information would be of interest about it in the methods and in the discussion. It is stated that “pathogens linked with SSI were identified from all SSI patient wounds”. The total number of pathogens in table 3 amounts to 86 for 86 patients. This would mean that only one pathogen was identified from every patient with SSI. Were no patients suffering from a polymicrobial SSI detected (which is relatively frequent in colon surgery)? Were no other pathogens identified than the seven presented in table 3? For example, Enterobacter spp. streptococci or Candida spp.? More details would be of interest on resistance patterns of the isolated bacteria: proportion of ESBL producers in E. coli and Klebsiella respectively, presence or not of carbapenemase-producing Enterobacteriaceae, resistance profile of Pseudomonas aeruginosa, resistance to vancomycine in enterococci. Mentioning the substances usually administered for antibiotic prophylaxis in these operations would help better realizing the magnitude of the problem of antibiotic resistance in this setting. Were only the significant variables in the multivariable analysis used for calculating the performance of the model for predicting SSI? Please specify. Discussion, paragraph 6. Mentioning whether glucose levels were not available for the included patients together with albumin levels or were available but not analyzed would be of interest since, irrespective of a history of diabetes, this could constitute, as stated, a risk factor for SSI. Discussion, paragraph 9. The following sentence is hard to understand: “Furthermore, our study revealed that the prevalence of SSI in large, pancreatic, and biliary surgeries was lower than in intestinal procedures; although this association was not statistically significant.” Does “large” mean large bowel? Then “intestinal” might mean small bowel. Please clarify. In addition, please refer to comments 5 and 6 above for possible modifications in the discussion about this result. Discussion, paragraph 10. It is stated that a long duration may induce weaning prophylactic antibiotic concentration. Studies have shown the importance of re-dosing when this duration reach the half-life of the administered antibiotic and guidelines recommend it. This could be mentioned here and cited as a mean to lower SSI rates. Discussion, paragraph 11. Please refer to comments 11, 12, and 13 above and possibly take them into account for extending the discussion about antibiotic resistance in this paragraph. Limitations, 3 rd sentence. Does “clinical identification” mean that no radiological or laboratory markers were used to help for the diagnosis of SSI? If yes, this should be specified in the methods. If not, underreporting might be due to interobserver variability if persons with different backgrounds did it (e.g. surgeons, infectious diseases physicians, infection control nurses). Limitations, 4 th sentence. Internal and external validation on other datasets or prospectively should be mentioned as a mean to consolidate these findings. Typos. Table 1: “During 1 hour of operation” instead of “During 1 house of operation”. Table 3: “Pseudomonas aeruginosa” instead of “Pseudomonas aerugisa”. Terminology. The same words should be used through the different tables (e.g. “surgical status” in table 1 instead of “operative type” in tables 4 and 5). Consider using “operation duration” instead of “operative time”. References 13 and 14 are identical. Reference 18 corresponds to a correction: please mention the original publication. (The source data are available but the corresponding file could not be opened.) Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Healthcare associated infections, clinical infectious diseases. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 23 May 2024 Faisal Ahmed, Urology Research Center, Al-Thora General Hospital, Department of Urology, School of Medicine, Ibb University of Medical Sciences, Ibb, Yemen Dear reviewer Thank you very much for reading and reviewing my manuscript. This is an interesting and well-written study aiming at determining a prediction rule for surgical site infection after digestive surgery in a developing country. It gathered a substantial number of parameters for univariate and multivariable analysis to develop a prediction model that performs better than the classical NNIS index. The authors might want to consider the comments and questions below and revise their paper accordingly. The abstract mentions an SSI rate of 15% (79/525), whereas the results section and the discussion state 16.4%. (86/525) Answer: Thank you. We apologize for this mistake. The exact number was revised in the abstract section. The abstract states that the majority of SSI were superficial but detailed results on the depth of SSI (superficial, deep, organ/space) are not provided in the results section. These data would be interesting by type of surgery. Answer: Thank you. The SSI type was added to the result section (Causative Pathogens section). The inclusion criteria state that all eligible patients between June 2015 and October 2022 were included, reaching 525 patients in about 7 years. Knowing the number of patients excluded would be of interest. Answer: Thank you. Unfortunately, the total number of patients was not accurately calculated. For that, we avoided mentioning the total patient numbers. Precisions on how SSIs were detected would be of interest. Was the diagnosis made by surgeons and infection control personnel? Were all the patients followed up after discharge? If yes, by systematic visits? All SSIs were microbiologically documented. Was it because samples were taken from all patients with a clinically diagnosed SSI or because positive lab results were used to identify patients with SSI? Answer: Thank you. Regarding infection control personnel, it was corrected. Regarding patients followed up: yes. As they were operated, it is usually to have a regular follow-up. Additionally, we mentioned that they underwent systematic visits. Regarding microbiology documentation, all patients had culture and we mentioned it in the data collection section. The main causes of sample collection are the patient symptoms and the SSI suspected. Operations are grouped into four categories (small bowel, large bowel, biliary, and pancreatic) in the description of the population analyzed. More details would be interesting to know which operations were included in these four categories, e.g. how many cholecystectomies were included in biliary surgery? Were appendectomies included in large bowel surgery or only colon surgery? Did large bowel surgery include rectal surgery? Answer: Thank you. We did not collect the data regarding These operations are then grouped into two categories (small bowel and others) in the statistical analyses. Although small bowel surgery represents the highest number of included operations, grouping large bowel surgery with biliary surgery appears counterintuitive, especially if cholecystectomies, which are much less at risk than colon surgery, represent the majority of biliary surgery. Could the results have been different and reached statistical significance if the comparison had been made between Large bowel and others rather than between small bowel and others? Answer: Thank you. We revised it as you mentioned. However, it was not statistically significant as we mentioned in table 4. Some continuous variables such as age, hospital stay, BMI or temperature were stratified into binomial variables for the statistical analyses. Did it imply a loss of power for detecting risk factors and perhaps better determine a cut-off for the prediction? This applies particularly for age which could have been considered as an ordinal variable and stratified first in ten-year categories. Answer: Thank you. All the continuous variables were converted into categorical variables for a better presentation of the nomogram. This statement was mentioned. The timing of shaving was found significant but shaving is not recommended by international guidelines and may constitute a risk factor for SSI (cf. for example reference 2 in the present paper). Is shaving systematically done in this hospital? Avoiding it according with guidelines could constitute a simple means for decreasing SSI rates that could be mentioned in the discussion. Answer: Thank you. This item was revised to be Hair removal. We mentioned this issue in the discussion section. It is stated that variables with a p value <0.2 in univariate analysis were fitted for logistic regression but “antibiotic timing” and “operative type”, which had both higher p values in univariate analysis (p=0.454 and p=0.506, respectively, as presented in table 4) are nevertheless part of the multivariable model (table 5). More details would be useful for a better understanding. Answer: Thank you. To better understand, we revised the Statistical analysis section. 10. Do all the operations performed in digestive surgery in this hospital correspond to open surgery? Since operations done with a laparoscope have been shown to be less at risk for SSI, information would be of interest about it in the methods and in the discussion. Answer: Thank you. Unfortunately, the laparoscopic equipment is not available in our hospital. For that, we avoided mentioning the laparoscopic procedures. 11. It is stated that “pathogens linked with SSI were identified from all SSI patient wounds”. The total number of pathogens in table 3 amounts to 86 for 86 patients. This would mean that only one pathogen was identified from every patient with SSI. Were no patients suffering from a polymicrobial SSI detected (which is relatively frequent in colon surgery)? Were no other pathogens identified than the seven presented in Table 3? For example, Enterobacter spp. streptococci or Candida spp.? Answer: Thank you. This was the result reported by the laboratory. 12. More details would be of interest on resistance patterns of the isolated bacteria: proportion of ESBL producers in E. coli and Klebsiella respectively, presence or not of carbapenemase-producing Enterobacteriaceae, resistance profile of Pseudomonas aeruginosa, resistance to vancomycin in enterococci. Answer: Thank you. We did not collect the data regarding the antibiotic sensitivity or resistance. 13. Mentioning the substances usually administered for antibiotic prophylaxis in these operations would help better realize the magnitude of the problem of antibiotic resistance in this setting. Answer: Thank you. it was mentioned in the data collection section. 14. Were only the significant variables in the multivariable analysis used for calculating the performance of the model for predicting SSI? Please specify . Answer: Thank you. To better understand, we revised the Statistical analysis section. 15. Discussion, paragraph 6. Mentioning whether glucose levels were not available for the included patients together with albumin levels or were available but not analyzed would be of interest since, irrespective of a history of diabetes, this could constitute, as stated, a risk factor for SSI. Answer: Thank you. We mentioned this issue in the discussion section. 16. Discussion, paragraph 9. The following sentence is hard to understand: “Furthermore, our study revealed that the prevalence of SSI in large, pancreatic, and biliary surgeries was lower than in intestinal procedures; although this association was not statistically significant.” Does “large” mean large bowel? Then “intestinal” might mean small bowel. Please clarify. In addition, please refer to comments 5 and 6 above for possible modifications in the discussion about this result. Answer: Thank you. It was revised as you mentioned. 17. Discussion, paragraph 10. It is stated that a long duration may induce weaning prophylactic antibiotic concentration. Studies have shown the importance of re-dosing when this duration reaches the half-life of the administered antibiotic and guidelines recommend it. This could be mentioned here and cited as a means to lower SSI rates. Answer: Thank you. It was added as you mentioned. 18. Discussion, paragraph 11. Please refer to comments 11, 12, and 13 above and possibly take them into account for extending the discussion about antibiotic resistance in this paragraph. Answer: Thank you. We did not collect the data regarding the antibiotic sensitivity or resistance. 19. Limitations, 3rd sentence. Does “clinical identification” mean that no radiological or laboratory markers were used to help with the diagnosis of SSI? If yes, this should be specified in the methods. If not, underreporting might be due to interobserver variability if persons with different backgrounds did it (e.g. surgeons, infectious diseases physicians, infection control nurses). Answer: Thank you. The word clinical was removed. 20. Limitations, 4th sentence. Internal and external validation on other datasets or prospectively should be mentioned as a mean to consolidate these findings. Answer: Thank you. We added this issue as you recommended. 21. Typos. Table 1: “During 1 hour of operation” instead of “During 1 house of operation”. Table 3: “Pseudomonas aeruginosa” instead of “Pseudomonas aerugisa”. Answer: Thank you. It was revised through the manuscript. 22. Terminology. The same words should be used through the different tables (e.g. “surgical status” in Table 1 instead of “operative type” in Tables 4 and 5). Consider using “operation duration” instead of “operative time”. Answer: Thank you. It was revised as you mentioned. 23. References 13 and 14 are identical. Reference 18 corresponds to a correction: please mention the original publication. Answer: Thank you. All references were rechecked and corrected The source data are available but the corresponding file could not be opened. Answer: Thank you. The revised dates are available at this address. https://data.mendeley.com/datasets/hk75wrwr6n/2 Is the work clearly and accurately presented and does it cite the current literature? Yes Answer: Thank you. Is the study design appropriate and is the work technically sound? Yes Answer: Thank you. Are sufficient details of methods and analysis provided to allow replication by others? Partly Answer: Thank you. If applicable, is the statistical analysis and its interpretation appropriate? Partly Answer: Thank you. Are all the source data underlying the results available to ensure full reproducibility? Yes Answer: Thank you. Are the conclusions drawn adequately supported by the results? Yes Answer: Thank you. Competing Interests No competing interests were disclosed. Answer: Thank you. Reviewer Expertise Healthcare associated infections, clinical infectious diseases. Answer: Thank you. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Troillet N. Peer Review Report For: Identification of predictive factors for surgical site infections in gastrointestinal surgeries: A retrospective cross-sectional study in a resource-limited setting [version 3; peer review: 1 approved, 2 approved with reservations] . F1000Research 2024, 12 :733 ( https://doi.org/10.5256/f1000research.148812.r192612) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/12-733/v1#referee-response-192612 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions Adjust parameters to alter display View on desktop for interactive features Includes Interactive Elements View on desktop for interactive features Competing Interests Policy Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. 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