Study of surgical site infection and it's associated factors among female undergoing hysterectomy in tertiary hospital of Kumaon Region

Background: Surgical site infections (SSIs) are infections that arise within 30 days following surgery, or up to one year if an implant is left remaining after the procedure. These infections specifically attack either the surgical wound or deep tissue at the site of the operation.

estimating the rate of surgical site infections (SSIs) and identifying their associ ated factors among females undergoing hysterectomy at a tertiary hospital in the Kumaon region.

All participants were included in the study after providing informed written consent. The study meticulously collected and analyzed data from these participants, focusing on their demographic details, surgical details, and post -operative outcomes, particu larly the development of surgical site infections.

The majority of the participants fell into the middle -age bracket, with significant numbers dealing with conditions like fibroids , adenomyosis, endometriosis and ovarian cysts, highlighting the bur den of gynecological issues leading to surgical interventions. The study identified an SSI occurrence rate of 17%. Escherichia coli emerged as the predominant pathogen responsible for SSIs, exhibiting substantial resistance to antibiotics like Ciprofloxaci n. Key risk factors for developing SSIs were notably linked to older age and higher body mass index (BMI).

The findings of this study highlight a significant association between anemia, diabetes, and the increased prevalence of surgical site i nfections (SSI). Both anemia and diabetes contribute to impaired immune function and delayed wound healing, making individuals with these conditions more susceptible to postoperative infections. Proactive strategies, including optimizing blood glucose levels in diabetic patients and addressing anemia before surgery, could play a crucial role in improving surgical outcomes and reducing healthcare costs associated with SSIs.

Surgical Site Infection, Hysterectomy, anemia, diabetes

Surgical site infection (SSI) continues to be a prevalent and widespread issue that leads to considerable illness and death, extends the duration of hospital stays, and ultimately raises healthcare expenses. SSIs are more likely to occur in patients with longer hospital stays, obesity, diabetes mellitus, smoking, and other related factors. The occurrence of a postpartum wound infection is contingent upon the intricate interaction of several elements. The primary cause of infection in the majority of postop erative wounds is endogenous. Exogenous infections primarily originate from the nasal or skin bacteria present in the operating team and are spread through the surgeon's hands or inadequate sterilization of the operating theatre. This includes the care provided before, during, and after the surgery [1]. Several crucial elements that can impact the likelihood of a subsequent infection include surgical procedures, skin preparation, timing, the style of wound closure, and the use of antibiotics to prevent infe ction following specific types of surgery. In addition, numerous other variables have been recognised as influencing the likelihood of infection, and healthcare practitioners should take them into account prior to, during, and following surgical procedures [2]. Surgical site infections (SSIs) were infections that occur at or around the surgical incision between 30 days of the procedure, or up to 1 year if an implant is inserted [3]. The Centre for Disease Control and Prevention (CDC) classifies surgical site infections into two categories: incision infections (superficial and deep) and organ space infections (affecting any part of the anatomy) [4]. These infections must develop within 30 days of the operation and are categorised based on the cleanliness of th e operative wounds: clean, clean-contaminated, contaminated, and dirty wounds [5, 6]. Surgical site infection poses a significant threat to patients and results in financial losses for International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 795 ~ health systems due to its complex causes. Achieving a quantitative and persistent reduction in the risk of surgical site infection is tough. In the past 20 y ears, significant progress has been achieved in the selection of methods for performing hysterectomies. While there have been reports on the occurrence and risk factors of surgical site infections (SSI) after total abdominal hysterectomy (TAH), there is cu rrently no available information on the occurrence or risk factors of post - hysterectomy SSI based on the specific method of hysterectomy [7,. 8, 9]. Enhanced comprehension of the risk variables associated with surgical site infections (SSI) following hystere ctomy can facilitate the focused allocation of resources towards mitigating modifiable risks, hence preventing infections [10]. Moreover, gaining knowledge about the risk factors for surgical site infections (SSI) following a hysterectomy might result in i mproved categorization of risk levels when reporting the quality of outcomes. The aim of our study is to determine the frequency of surgical site infections (SSI) within 30 days after different types of hysterectomy procedures, and to identify any characte ristics that may be related with an increased risk of SSI.

A Prospective Cohort study was conducted among all women undergoing hysterectomy during study duration who fulfills inclusion criteria in Obs & Gynae Department of Dr. Sushila Tiwari hospital, Haldwani. Duration of study was 18 months after approval of IEC whichever is early. Inclusion criteria  All patient willing to participate.  All cases undergoing hysterectomy (elective/emergency) in Dr Sushila Tiwari Hospital Haldwani. Exclusion criteria  All patients who do not want to participate.  Hysterectomy done outside Dr . Sushila Tiwari Hospital Haldwani. Sampling method Consecutive sampling Plan of study All women who underwent hysterectomy in the Obs & Gynae Department of Dr. Sushila Tiwari Hospital, Haldwani, and who fulfilled the inclusion criteria, were included in the study after taking informed written consent. Participants were followed up for a maximum period of 30 days to check for the developme nt of signs of wound sepsis, such as wound discharge, wound induration, wound edema, and wound gaping.  All participants' socio -demographic details, along with the presence of risk factors, were taken using a pre -tested schedule.  If a participant developed signs of sepsis as mentioned above, culture and antibiotic sensitivity testing were performed to identify the infection-causing organism as well as the antimicrobial resistance pattern. Study tools A pre -tested schedule was used to record socio - demographic details along with risk factors, culture and antibiotic sensitivity. Statistical analysis The data was compiled in MS Excel, and the analysis was done using appropriate statistical tests with SPSS version 16.

For age, the participants are categorized into three groups: those under 30 years old (1 participant, 1.0% of the total), those aged between 30 and 49 years (60 participants, 60.0%), and those over 49 years old (39 participants, 3 9.0%). The mean age of the participants is 47.2 years, with a standard deviation of 7.72 . Socioeconomic Status is classified into three categories: High, Middle, and Low. Among the participants, 19% are categorized as High SES (19 participants), 34.0% as M iddle SES (34 participants), and 47.0% as Low SES (47 participants). BMI (Body Mass Index) reveals that 34% of participants (34 individuals) are classified as Overweight, with a mean BMI of 29.1 and a standard deviation of 1.67. Fig 1: Genecological history of study participants Fibroids are reported in 41 participants, constituting 41% of the sample. Prolapse is high prevalence, reported by 30 participants, International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 796 ~ making up 30% of the sample. Endometriosis and Adenomyosis together accounts for 27 participants, accounting for 27% of the total samp le. Ovarian Cysts are noted in 2 participants, also making up 2% of the participants. None of the specified gynecological conditions, indicating a subgroup within the study population that is free from these particular health issues. Table 1: Past History of study participants (n =100) Past History Frequency Percentage Diabetes 12 12% Anemia 22 22% Hypertension 15 15% The table 1 presents the past medical history of study participants, detailing the prevalence of three specific conditions: Diabetes ( 12%), Anemia ( 22%), and Hypertension (15%). For Type of Anesthesia, the majority underwent spinal anesthesia (60.0%), followed by General anesthesia (27.0%) and epidural anesthesia (13.0%). Type of Incision was predominantly Pfannenstiel in 54.0% of cases, with midline incisions in 16.0%. Type of suture with Vicryl used in 100% of cases. The mean duration of surgery was 105 minutes, with a standard deviation of 23.7 minutes, indicating the average time taken for the procedures performed. Table 2: Post operative complications seen in study participants (n=100) Post-op Complications Frequency Percentage UTI 12 12% DVT 0 0% Wound Dehiscence 2 02% Wound Infection 15 15% None 79 79% The table 2 summarizes post -operative complications observed following hysterectomy procedures among study participants. The most prevalent complication is urinary tract infection (UTI), reported in 12 participants (12.0%), followed by wound infection and wound dehiscence, each noted in 15% and 02% of participants respectively. A majority of participants, 79%, did not experience any post-operative complications. Table 3: Development of SSI seen in study participants (n=100) SSI development Frequency Percentage Yes 17 17.0 No 83 83.0 The table 3 presents data on the development of Surgical Site Infections (SSI) following hysterectomy procedures among study participants. Out of the total, 17 participants (17.0%) experienced SSI, while the majority, 83 participants (83.0%), did not encounter such infections post-operatively. Among those who developed SSI, Escherichia coli ( E. coli) was the most frequently identified pathogen, present in 9 cases (53.0%). Methicillin -resistant Staphylococcus aureus (MRSA) and Staphylococcus aureu s were each identified in 4 cases, accounting for 23.5% each. Among the pathogens, 53.0% were resistant to Ciprofloxacin. Additionally, 23.5% were resistant to methicillin but sensitive to Vancomycin, while the same percentage (11.75%) showed resistance to Penicillin but were sensitive to Vancomycin. Another 11.75% w ere resistant to methicillin without reference to their sensitivity to other antibiotics. The distribution across age groups shows significant differences in the incidence of SSI (Chi square = 16.2, p = 0.0003). Participants over 49 years old had the highe st incidence of SSI (14 cases), followed by those aged 30 -49 years (3 cases). The age group under 30 years had no reported cases of SSI. There were no significant differences in SSI incidence across socioeconomic statuses (Chi square = 0.38, p = 0.8274). S SI cases were relatively evenly distributed among participants classified as High (4 cases), Middle (6 cases), and Low (7 cases) socioeconomic status. Significant differences were observed in SSI incidence based on BMI categories (Chi square = 6.84, p < 0.0089). Participants classified as Obese had a notably higher incidence of SSI (12 cases) compared to those classified as Overweight (5 cases). Table 4: Association of SSI with Gynecological History of study participants Gynecological History SSI SSI Percentage Statistics Endometriosis 1 33% Chi square: 11.4 p value: 0.161 Adenomyosis 6 25% Fibroids 7 17% Ovarian Cysts 1 50% Prolapse 2 6.6% Endometrial cancer 0 0% The table 4 presents the association between gynecological history and the occurrence of Surgical Site Infections (SSI) among study participants, along with the corresponding statistical tests. The distribution across gynecological history does not show any significant differences in the incidence of SSI (Chi square = 11.4, p = 0.161). Table 5: Association of SSI with Past History of study participants Past History SSI No SSI Statistics Diabetes 05 07 Chi square: 2.58 p value: 0.03 Anemia 7 15 Chi square-11.1 p value: 0.002 Hypertension 02 13 Chi square: 1.5 p value: 0.22 The table 5 presents the relationship between past medical history variables and the occurrence of Surgical Site Infections (SSI) following hysterectomy procedures, along with associated statistical tests. There is statistically significant association found between Diabetes and SSI (Chi square = 2.58, p = 0.03). Five cases of SSI were reported among those with Diabetes, while 07 cases were reported among those without. There is statistically significant association found between Anemia and SSI (Chi square = 11.1, p = 0.002). Seven cases of SSI were reported among those with Anemia, while 15 cases were reported among those without. There is a no statistically significant association between Hypertension and SSI (Chi square = 1.5, p = 0.22). Two cases of SSI were reported among those with Hypertension.

In our study, we explored demographic and health -related characteristics of 100 participants, summarizing the findings in terms of frequencies, percentages, and mean values along with standard deviations where applicable. The age distribution among the participants revealed a skewed older age group, with International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 797 ~ only 1% (1 participant) under the age of 30 years, and the majority falling within the 30 -49 years (60%) and over 49 years (39%) categories. The overall average age was 47.2 years, indicating a middle - aged cohort with a standard deviation of 7.72, which suggests a relatively tight age range among participants. Which is in consistent with study findings S. Latha, et al. study conducted in India found that women aged 55 and older had a higher rate of SSIs aft er hysterectomy, emphasizing the role of age and chronic conditions like diabetes in increasing infection risk. Socio-economic status (SES) was divided into three categories: High, Middle, and Low. The distribution was fairly even across these categories, with 19% of participants classified as having High SES, 34% as Middle SES, and 47% as Low SES. This diverse socioeconomic representation helps in understanding the influence of economic conditions on the health outcomes being studied. Regarding Body Mass Index (BMI), a significant portion of the study population was categorised as overweight (34%) with a mean BMI of 29.1 and a standard deviation of 1.67. The remaining 24% were categorized as obese. This high prevalence of overweight and obese participants is critical, as it underscores the potential health challenges in this demographic, which could include a higher risk of surgical site infection. This is in consistent with other study findings like study by Olsen MA, et al specifically looked at the increased risk of SSIs in obese patients undergoing abdominal surgery, finding that obesity was an independent risk factor, especially for deep and organ/space infections. Kudachi SS, Bhandare SD, Kumar A et al . study assessed the impact of obesity on SSI rates following abdominal surgeries. It found that obese patients had a higher rate of postoperative infections compared to non -obese patients, largely due to prolonged operative time and wound healing issues. Our study involving 100 participants highlights significant findings regarding the gynecological history and conditions leading to hysterectomy among women. An examination of the gynecological history shows a notable prevalence of fibroids (41%), the highest among surveyed cond itions, affecting nearly more than one third of the participants. Similarly, both endometriosis and adenomyosis together affect 27%of the sample, suggesting a commonality in the incidence of these conditions, which are often associated with significant morbidity which is in consistent with findings of Choi EJ et al, the analysis of 61,516 patient records over a three -year period, the prevalence of adenomyosis was found to be 12.4% in 2009, increased slightly to 12.5% in 2010, and then to 13.3% in 2011. (11). For endometriosis, the prevalence rates were 9.3% in 2009, 9.4% in 2010, and decreased to 9.1% in 2011. Prolapse are also prevalent in 30% of the participants, further emphasizing the frequency of these gynecologic issues in our study population. Interestingly, ovarian cyst is relatively less common, reported by only 2% of the participants. Regarding the past medical history, a substantial number of participants report chronic conditions such as diabetes 12%, anemia 22%, and hypertension 15%. These conditions may contribute to or complicate gynecological issues, underlining the importance of managing these chronic diseases alongside gynecological care. In our study prevalence of SSI was highest in medical conditions like anemia and diabetes, that is around 31% and 41%.Both Indian and international studies support the association between anemia and increased SSI risk in hysterectomy patients. Miller et al . (2013) identified preoperative anemia as a significant risk factor for SSIs in gynecologic surgeries. Mukherjee et al . (2019) in India highlight that moderate to severe anemia (hemoglobin <10 g/dL) is associated with a notably higher risk of infection compared to mild anemia. In our study assessing the intra -operative variables of 100 participants undergoing hysterectomy, we observed a predominant preference for spinal anesthesia, which was use d in 60% of cases. This was followed by General anesthesia at 27% and epidural anesthesia at 13%. Regarding the type of incision made during the surgery, Pfannenstiel incisions were more common, used in 54% of cases, compared to midline incisions which were utilized in 16% of cases. This could suggest a preference for Pfannenstiel incisions due to factors like reduced post -operative pain and better cosmetic outcomes, which align with existing literature. The selection of sutures varied, with Vicryl being th e most frequently used (100%). The average duration of the surgeries was 105 minutes, with a standard deviation of 23.7 minutes, indicating a moderate variability in the length of these procedures which could be influenced by factors such as the complexity of the case and surgeon experience.  Post-operatively, the majority of our participants (69%) did not experience any complications, which highlights the efficacy of the surgical and management protocols in place. However, urinary tract infections were the most reported complication, affecting 12% of the participants. Wound infection and wound dehiscence each occurred in 17% of the cases, necessitating consideration for enhanced prophylactic measures and post -operative care. The very low incidence of wound dehiscence (2%) suggests effective sterility and antibiotic protocols during and after surgery. In our study, we observed the development of Surgical Site Infections (SSIs) in a cohort of 100 individuals who underwent hysterectomy procedures. The data revealed that 17% (n=17) of the partici pants developed SSIs, while the vast majority, 83% (n=83), did not experience any postoperative infections. Escherichia coli ( E. coli ) was the most frequently encountered pathogen, found in 53% of the SSI cases. Methicillin-resistant Staphylococcus aureus (MRSA) and Staphylococcus aureus were identified in 23.5% of cases each. This distribution is noteworthy as it highlights the common bacterial agents responsible for post- surgical complications and underlines the importance of targeted antibiotic prophylax is. Regarding antibiotic resistance, 53% of the pathogens were resistant to Ciprofloxacin, which poses a challenge for treatment.  In our study prevalence of SSI was much more in abdominal hysterectomy as compared to vaginal hysterectomy which is in consist ent with other studies such as those by Wright et al . (2011) and Miller et a l. (2013) have consistently shown higher SSI rates in abdominal hysterectomies compared to vaginal or laparoscopic procedures. This trend holds true within India, as seen in studies like Mukherjee et al . (2019), which report higher infection rates in abdominal hysterectomies.

The findings of this study highlight a significant association between anemia, diabetes, and the increased prevalence of surgical site infections (SSI). Both anemia and diabetes contribute to impaired immune function and delayed wound healing, making indi viduals with these conditions more susceptible to postoperative infections. This underscores the need for preoperative screening and management of these risk factors to reduce SSI incidence. Proactive strategies, including International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 798 ~ optimizing blood glucose levels i n diabetic patients and addressing anemia before surgery, could play a crucial role in improving surgical outcomes and reducing healthcare costs associated with SSIs. Conflict of Interest Not available Financial Support Not available

1. Chang DT, Lee AJ. The economics of surgical site infections in healthcare settings. Health Economics. 2019;28(8):1031–1042. 2. Singh R, Patel H. Postoperative care and the incidence of surgical site infections. Journal of Postoperative Management. 2023;5(2):112–123. 3. Moore J, Thompson C. The effectiveness of prophylactic antibiotics in surgery. Clinical Pharmacology & Therapeutics. 2022;111(4):859–874. 4. Ali M, Khan A. Surgical site infections in low - and middle- income countries: a critical review. Global Health. 2021;17:22. 5. Brown L, Patel S. Incidence of surgical site infections in pediatric surgery: a systematic review. Pediatric Surgery International. 2020;36(3):291–300. 6. Wilson E, Roberts T. Infection control practices in operating rooms: from traditional methods to modern technologies. Journal of Hospital Infection. 2019;101(4):400–411. 7. Skayzynska J, Ciencala A, Madry R, et al . Hospital infection in general surgery wards. Przegl Epidemiol. 2000;54(3–4):299–304. 8. Wong ES. Surgical site infections. In: Mayhall CG, editor. Hospital epidemiology and infection control. 1st ed. USA: Williams and Wilkins; 1996. p. 154–174. 9. Berard F, Gandon J. Factors influencing the incidence of wound infection. Ann Surg. 1964;160:32–81. 10. Zaman F. Profile of wound infection following caesarean section delivery at Institute of Child & Mother Health, Matuail, Dhaka [dissertation]. Dhaka: Bangladesh College of Physicians and Surgeons; 2011. 11. Choi EJ, Cho SB, Lee SR, Lim YM, Jeong K, Moon HS, et al. Comorbidity of gynecological and non -gynecological diseases with adenomyosis and endometriosis. Obstet Gynecol Sci. 2017;60(6):579 –586. doi:10.5468/ogs.2017.60.6.579. How to Cite This Article Rani M, Solanki RS, Kumari R, Kamal. Study of surgical site infection and it's associated factors among female undergoing hysterectomy in tertiary hospital of Kumaon Region . International Journal of Clinical Obstetrics and Gynaecology. 2026;10(3):794-798. Creative Commons (CC) License This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution -Non-Commercial-Share Alike 4.0 International (CC BY -NC-SA 4.0) License, which allows others to remix, tweak, and build upon the work non -commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.