Profile and impact of antimicrobial resistance related to surgical site infections after abdominal surgery in a resource-limited country: a prospective observational cohort study

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A one-year prospective observational cohort study on SSIs after abdominal surgery is being conducted in our department of surgery; with the goal to figure out the incidence, root causes, outcomes, and surveillance. Considering the amount of antimicrobial resistance (AMR) in SSIs, we thought to study its profile and impact on outcomes; in order to guide SSIs management and antibiotic stewardship. Methods After 8 months of this prospective observational cohort study (February 1, 2024-September 31, 2024), all patients above 15 years-old who had undergone surgical intervention in abdominal (digestive and parietal) surgery were included. The variable of interest, for this study, was the occurrence of SSI as well as its clinical and bacteriological characteristics, the antibiotic resistance phenotype, and outcomes. The WHO Protocol for surgical site infection surveillance with focus on settings with limited resources is used to compile parameters. Results The study involved 328 patients; the incidence of SSIs was 17.9% (n = 59). The mean age of patients with SSIs was 51 years and the sex ratio was 1.1. The SSIs was Superficial incisional (SI) in 81.3% (n=48); Deep incisional (DI) in 8.4% (n=5) and Organ/space (OS) in 10.1 % (n=6). Bacteria were identified for 37 patients (62.7%), with 44 germs found. The most common bacteria were Enterobacteria in 81.8% (n=36) of cases with Escherichia coli in the lead (50% of 44), followed by Klebsiella pneumoniae (13.6% of 44) and Enterobacter Cloacae (9% of 44). Non-fermentative Gram-negative bacilli were noted in 7 patients (16%); with Pseudomonas aeruginosa in 5 patients. 95.4 % (42/44) of bacteria were found to have AR phenotype. The resistance phenotype within Enterobacteria was Extended-spectrum beta-lactamase (ESBL) in 50% of cases, followed by Hypersecretion of cephalosporinase (HCASE) in 11.3% and then Penicillinase (PASE) in 11.3%. Among the non-fermentative gram-negative bacilli, in particular for Pseudomonas aeruginosa, the Ceftacidim-Resistant phenotype was noted for all (100%). SSIs were treated by wound care for the most (86.4%, n=51). Antibiotics were indicated for 5 patients (8.4%),1 DI and 4 OS. Surgery was indicated for 3 patients (5%), 1 DI and 2 OS. Negative pressure therapy was indicated for 5 (8.4%), 2 DI and 3 OS. The overall mortality was 10.1% (n=6). The main cause of death was septic shock related blood stream contamination with Multidrug resistance (MDR) bacteria. Conclusion Enterobacteria were the most founded germs; with a predominantly ESBL resistance phenotype. SSIs and AMR are twin's threats. Antibiotics were not mandatory for SSIs treatment. In fact, SSIs contribute to occurrence of AMR phenotype and MDR bacteria. The main cause of death related to bloodstream nosocomial MDR infections, shows that SSIs increase the length of stay and the risk of nosocomial infection with MDR bacteria. In our context, improving surgical wound management, antibiotic stewardship, multidisciplinary collaboration, and multimodal prevention strategies will reduce SSIs and avoid AMR for a sustainable and safe surgical practice. abdominal surgery antimicrobial resistance low resource settings Extended-spectrum beta-lactamase surgical safety surgical site infections Background Surgical site infections (SSIs) remain a substantial cause of morbidity, accounting for 25% of Hospital acquired infections (HAIs). SSIs is a major cause of hospital mortality, increasing to a factor 10 the risk of death. SSI is the most costly HAI type ; and increase hospital length of stay by 9.7 [ 1 ]. In addition to this, they also have a significant quality of life and economic impact on the population and society [ 2 , 3 ]. The global incidence of surgical site infections (SSIs) is estimated by WHO between 3–50%, depending on the type of surgery, and is particularly high in low- and middle-income countries (LMICs), where SSIs are the most frequently reported healthcare-associated infection (HAI) [ 4 ]. Antimicrobial resistance (AMR) poses a societal-level hazard, with an estimated 1.27 million deaths attributable to bacterial AR globally in 2019 [ 5 ]. Escherichia coli (E. coli) and Staphylococcus aureus, the two leading pathogens for deaths associated with antibacterial resistance, are also the two most prevalent bacterial species isolated from postoperative infections [ 6 , 7 , 8 ]. Contracting SSI increases antibiotic use seven-fold [ 9 ]. Because of AMR, the miracle impact of antibiotics to reduce infectious morbidity in surgery is rapidly waning; so, the prevention and surveillance of SSIs is absolutely necessary. A one-year prospective observational cohort study on Surgical site infections (SSIs) after abdominal surgery is being conducted in our surgical department; with the the aim to figure out incidence, root causes, outcomes and to foster a sustainable surveillance system with collaborating physicians of infectious diseases, anesthesiologists, and biologists. Considering the amount of AMR in preliminary checking, we thought to study its profile and impact on outcomes; in order to guide SSIs management and antibiotic stewardship. Methods Study design This prospective observational cohort study is being conducted in the department of visceral surgery since February 1, 2024. Our hospital is a level 4 military teaching hospital in Senegal, West Africa, a Low-middle income country (LMIC); with an estimated population of 18 million in 2023. The level 4, according to United Nations (UN) definition based on the treatment capabilities and capacity of a medical unit, offers highly specialized care, including intensive care, trauma surgery, and advanced diagnostic services. WHO Protocol for surgical site infection surveillance with focus on settings with limited resources [ 10 ] is used to select and compile parameters of study. Operational definitions Surgical site infection occurs near or at the incision site and/or deeper underlying tissue spaces and organs within 30 days of a surgical procedure performed (or up to 90 days for implanted prosthetics) [ 1 ]. Assessment of the degree of contamination of a surgical wound at the time of the surgical procedure is based on four wound classifications: Clean (class 1), Clean-Contaminated (class 2), Contaminated (class 3), and Dirty/Infected (class 4) [ 1 ]. Multidrug resistance (MDR) refers to resistance at least one antimicrobial agent in three or more antimicrobial classes. Antibioprophylaxis was systematic according to standard of care and to our antibiotic stewardship. After surgery antibiotics were administered in class 3 for 2 days hours; and in class 4 for 5 days. Diagnosis of SSIs was made according to CDC (Center for disease control and prevention) [ 1 ] criterion and classified: Superficial incisional (SI); Deep Incisional (DI) and Organ/Space (OS). Trained personnel collected SSIs samples (pus or serosities), aseptically (sterile syringe or sterile cotton-tipped swabs from inside to outside). Antibiotics for SSIs was indicated in face of proof of SSIs and systemic inflammatory response syndrome or sepsis. Patient recruitment Over 8 months (February 1, 2024-September 31, 2024), we included all patients aged over 15 years who had abdominal (digestive or parietal) elective or emergency surgery. Consent was acquired for all patients, and parental consent for patients under 15 years old. Patients who developed signs and symptoms of SSI and given consent for the follow up were enrolled. Decision to identify eligible patients as SSI cases were done by attending physicians. All patients were followed up even upon discharge and those who presented a SSI within 30 days, 90 days in the case of a prosthesis were identified. We did not include patients who died in less than 15 days and those who had proctological, gynecological or urological pathology. SSIs Sampling When the suppuration was deep (fascia / muscle) or organ (postoperative or persistent peritonitis) the pus was collected using a syringe which was at once sent to the laboratory. For superficial suppurations (fascia, subcutaneous cellular tissue), samples were taken using a syringe if the suppuration was abundant or by swabbing if it was minimal after disinfection of the surgical wound. Data and parameters collection Datas were compiled according to the WHO Protocol for surgical site infection surveillance with focus on settings with limited resources [ 10 ]. Parameters included: incidence of SSIs, clinical characteristics, preoperative, operative and post operative data related to SSIs, previous antibiotic therapy, bacteria and their phenotype of resistance, outcomes and mortality. Bacteriological results were collected from the laboratory after assessment of attending biologists. Resistance phenotypes were classified by: Extended spectrum beta lactamase (ESBL) Low-level penicillinase (LL-PASE) High-level penicillinase (HL-PASE) Hypersecretion of cephalosporinase (HCASE) Carbapenemase (CarbASE) Ceftacidim-Resistant (Cefta-R) Chromosomal cephalosporinase (ChromCASE) Data management and statistical analysis Data were included anonymously on « kobocollect » website ( https://kf.kobotoolbox.org ) and exported to an Excel file and then analyzed using version 4.3.3 of the R software. According to their distribution, quantitative variables were represented using either means ± standard deviations (SD) or medians and their extremes (IQR). Qualitative variables were represented using frequency and percentages. Results Peri-operative characteristics We collected 328 patients; the surgical site infection (SSI) rate was 17.9% (n = 59). The mean age of patients who presented with SSI was 51 years; there were 28 women and 31 men (sex ratio 1.1). Most patients who had SSI were classified ASA 1 (53%) and had an emergency operation (88.1%). Surgical interventions were class 2 in 54% of cases (Table I). All our patients had received antibiotic prophylaxis or therapy according to the Altemeier class and to the surgical diagnosis. The most used antibiotic for prophylaxis was cefazolin (54.8%); ampicillin 22.5%, amoxicilline-clavunate (11.6%). SSIs characteristics The mean time to occurrence of SSIs was 9 days and presented as purulent wound discharge in 71% (n = 42) of cases. The SSIs was Superficial incisional (SI) in 81.3% (n = 48); Deep incisional (DI) in 8.4% (n = 5) and Organ/space (OS) in 10.1% (n = 6) (Table II). Among patients with ISO, 60.8% were already on antibiotics according to surgical diagnosis; ceftriaxone-metronidazole combination was given for the most patients (49.2%). Microbiology Bacteria were identified for 37 patients (62.7%), with 44 germs found (Table III). Sample was mono-microbial in 83.7% of patients (n = 31), bi-microbial (13.5% − 5 patients) and tri-microbial (2.7% − 1patient). The most common bacteria were Enterobacteria in 81.8% (n = 36/44) of cases; with E. coli in the lead (50% of 44), followed by Klebsiella pneumoniae (13.6% of 44) and Enterobacter cloacae (9% of 44). Non-fermentative Gram-negative bacilli were noted in 7 patients (16% of 44); with Pseudomonas aeruginosa in 5 patients. Aeromonas hydrophila was found in 1 sample (2.2%). AMR phenotype was found in 95.4% (42/44) of bacteria specimens (Table IV). The resistance phenotype within Enterobacteria was 94.6% (35/36); with ESBL in 50% of cases, followed by HCASE in 11.3% and then PASE in 11.3%. Among the non-fermentative gram-negative (NFGN) bacilli, in particular for Pseudomonas aeruginosa, the Ceftacidim-Resistant phenotype was noted for all (100%). Treatment and outcomes SSIs were treated by wound care for the most (86.4%, n = 51) in bed hospital and after discharge. Negative pressure therapy (NPT) was indicated for 5 (8.4%); 2 DI and 3 OS. Surgery was indicated for 3 patients (5%); 1 DI and 2 OS. Antibiotic therapy was indicated for 5 patients (8.4%); 1 DI and 4 OS. Antibiotic therapy was used in addition to 3 surgeries and 2 NPT. The antibiotic molecule according to resistance phenotype was vancomycin in combination with imipenem (2 patients), piperacilline-tazobactam (1patient), amoxicillin-clavunate (1patient) and ceftriaxone + metronidazol. The overall mortality was 10.1% (n = 6). One SI SSIs death is related to pulmonary embolism. Two DI SSIs deaths are related to septic shock. Three OS SSIs deaths are related to septic shock (n = 2) and Gastrointestinal bleeding (n = 1). Organ/Space SSIs are related to surgical complications (anastomotic leakage). The main cause of death was septic shock (4 patients/6–66%) related to blood stream contamination with Multidrug resistance (MDR) bacteria. Discussion Incidence of SSIs The incidence of SSI varies from 0.1 to 50.4% depending on surgical specialties and countries [ 11 ]. In digestive surgery, a multicenter study (Globalsurg 2) including several countries with different incomes studying the rate of SSI after gastrointestinal resection demonstrated an incidence of SSI that varied significantly according to the human development index (HDI) with SSI rates inversely proportional to the HDI: high HDI (9.45% SSI), medium HDI (14.0% SSI) and low HDI (23.2% SSI) (p < 0.001) [ 12 ]. Our SSI rate of 17.9% is slightly lower compared to other countries with a low HDI; in fact, we had included in our series all patients of abdominal surgery (with or without gastrointestinal resection); knowing that patients having an intestinal resection (Altemeier class > 1) have a higher risk of having an ISO [ 13 ]. Fartouah et al had noted an incidence of 5.1% in a study carried out in the same department in 2004 [ 14 ]. This low incidence was explained by the fact that patients who had an SSIs after their discharge were not taken into account. Many studies, as other African series, are not comparable because of heterogeneity of patients and study design with incidence of SSIs between 10% and 30% [ 15 , 16 ]. The fact is that SSIs incidence is too high in LMICs, despite existing proof of efficient preventive measures and multimodal strategies to control the burden [ 17 ]. One reality for us is that Superficial incisional SSIs are predominant suggesting insufficiency in surgical wound management, lack of wound protector for open surgeries and low practice of minimal invasive surgery for contaminated classes. Microbiology and Resistance phenotype The type of germ isolated in SSIs varies according to the infectious flora; Gram-positive cocci (Staphyloccoccus aureus, Coagulase-negative Staphylococcus) are more often noted in SSIs after clean surgery (orthopedics and cardiac surgery). Enterobacteria (E. coli, Enteroccocus sp…) are founded after digestive contaminated surgery [ 7 , 18 ]. Because of abdominal surgical site in our department, Enterobacteria were the most isolated germs founded (84%). The absence of staphylococcus is a good point, fostering our practice of hygiene in the operating rooms. SSIs are often poly-microbial with anaerobic and aerobic microorganisms. This poly-microbial etiology is more important in visceral surgery with a rate of 40% during contaminated surgery [ 3 ]. The poly-microbial sampling rate is lower in our study (23%), but we did not consider yet to analyze different classes of contamination. The prevalence of Enterobacteria producing ESBL has increased worldwide [ 18 , 19 ]. The prevalence of Enterobacteria producing ESBL in patients with intra-abdominal infection is increasing over time in Asia, Europe, Latin America, the Middle East, North America and the South Pacific; in Africa this prevalence has been estimated to 10% in 2013 [ 18 ]. When looking at our cohort of SSIs, AMR resistance phenotype concern almost all cases (42/44–94.5%); with 50% of ESBL found for Enterobacteria and 100% of Ceftacidim-Resistant for NFGN bacilli. This observation shows that occurrence of SSIs is related to occurrence of AMR phenotype. SSIs and AMR are twin's threats. Also, antibiotic therapy does not prevent the occurrence of SSIs, considering 60.8% of our patients which were earlier on antibiotics with no sensibility on SSIs bacteria specimens. Treatment and outcomes Despite the virulence of certain isolated pathogens, only 5 patients benefited from targeted antibiotic therapy in addition to surgery or drainage because they presented signs of sepsis. Wound care of the surgical incision, conservative treatment for leaks in surgical drainage orifices and NPT were enough to achieve clinal improvement for the most. Antibiotics are not mandatory for SSIs in the absence of sepsis. The risk of mortality is less related to post-operative complications (anastomotic leakage, pulmonary embolism, bleeding), but is increased by AMR and MDR contamination. The mortality rate associated with these infections average is 3–5% (10.1% for us), and 75% of those deaths are directly attributable to the SSI [ 20 ]. In a recent large retrospective cohort from 203 to 2008 [ 21 ], the consequences of post-operative infection (including SSIs), was precisely studied. Infection in the 30-day period following surgery leads to a significantly higher risk of infection and mortality in the subsequent year (hazardratio, 3.17; 95% CI, 3.05–3.28 and hazardratio,1.89 ; 95% CI, 1.79–1.99, respectively). Overall, 24810 patients (3.8%) died during follow-up. Observed mortality rate in those in the exposure group was 12.9% (3067 of 23815) compared with 3.4% (21743 of 635671) in the control group. « Post-operative infection is a pervasive mediator of patient mortality » [ 22 ]. It is fundamental for health care workers : to understand the extent of the consequences of SSIs ; to increase their knowledge and motivation ; to implement precautions, and take prevention recommendations very seriously [ 20 ]. Early recognition is also of extreme importance to quickly manage SSIs before they progress to serious complications ; for that multidisciplinary collaboration is crucial. Improving patient safety in today’s hospitals worldwide requires a systematic approach to combat AMR and to prevent and treat infections appropriately. The two concepts go hand-in-hand [ 23 ]. AMR has emerged as one of the major public health problems of the twenty-first century [ 24 ]. Definitly, this preliminary results is a real life portrait and awareness, that will be the factual beginning of our commitment against SSIs. Limitations This preliminary descriptive study does not consider cost and length of stay related to SSIs. Digestive and non-digestive surgeries are not separately extracted for this study. The project is not achieved yet but give us real-life orientations to adapt SSIs prevention and management. Conclusion The incidence of SSIs in our context is 17.9%. This study allowed us to know the local ecology of pathogens after SSIs, and the scientific knowledge to improve our practice. SSIs and AMR are twin's threats. Antibiotics therapy is not mandatory for SSIs, highlighting the role of the surgeon in the earlier diagnosis and multimodal management of these infections. In fact, SSIs contribute to occurrence of AMR phenotype and MDR bacteria. The main cause of death related to bloodstream nosocomial MDR infections, shows that SSIs increase the length of stay and the risk of nosocomial infection with MDR bacteria. In our context, improving surgical wound protection, efficient antibiotic stewardship, collaboration of physicians and implementing an integrated strategy with involved physicians, will reduce SSIs and avoid AMR for a sustainable and safe surgical practice. Abbreviations Antimicrobial resistance (AMR) Multidrug resistance (MDR) Pseudomans aeroginosa (Pseudomonas a.) Enterobacter aerogenes (Enterobacter a.) Escherichia Coli (E. coli) Non-fermentative gram-negative bacilli (NFGN bacilli) Aeromonas hydrophila (Aeromonas h.) Extended-spectrum beta lactamase (ESBL) Low-level penicillinase (LL-PASE) High-level penicillinase (HL-PASE) Hypersecretion of cephalosporinase (HCASE) Carbapenemase (CarbASE) Ceftacidim-Resistant (Cefta-R) Chromosomal cephalosporinase (ChromCASE) Declarations Clinical trial number : not applicable Funding No funding is available yet. Author contributions Faye M, Diop M, Diémé E and Sall I were principal researchers and conceived the study; with data collection, analysis, interpretation of the findings, drafting the manuscript, and write-up. All authors took part to manuscript conception and provided critical intellectual content. Acknowledgements The authors would like to thank physicians, nurses, and microbiologists from all the study sites who helped us undertake this study. Lastly, our gratitude goes to all the study participants. Availability of data and materials Research data supporting the findings of this study have been compiled in our department. All necessary data is provided within the manuscript. The data sets generated during and/or analyzed during the current study are available from the corresponding authors on reasonable request. Ethics approval and consent to participate Ethics approval was obtained from local ethics committee of the Military Teaching Hospital. Data were collected after full informed and written consent or assent was obtained from each participant. Consent for publication Not applicable. Competing interests All authors declare that they have no competing interest. References Surgical Site Infection Event (SSI). Center for Disease Control and Prevention (CDC). National Healthcare Safety Network (NHSN). 2023. https://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual current.pdf. (Accessed 09 oct 2024). Allegranzi B, et al. Burden of endemic health-care-associated infection in developing countries : systematic review and meta-analysis. Lancet. 2011;377(9761):228–41. Lermite É, Christou N, Baillet P. Infections du site opératoire : rapport présenté au 122e Congrès français de chirurgie, Paris, 2-4 septembre 2020. Monographies de l’Association française de chirurgie. Arcueil : Arnette ; 2020. Global Guidelines for the Prevention of Surgical Site Infection [Internet]. Geneva : World Health Organization, 2018. http.www.ncbi.nlm.nih.gov/books/NBK536404/. (Accessed 15 oct 2023). Murray CJ, Ikuta KS, Sharara F, Swetschinski L, Robles Aguilar G, Gray A et al. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet. 2022; 399:629–655. Birgand G, Dhar P, Holmes A. The threat of antimicrobial resistance in surgical care: the surgeon’s role and ownership of antimicrobial stewardship. BJS. 2023; 110:1567–1569. Worku S, Abebe T, Alemu A, Seyoum B, Swedberg G, Abdissa A, et al. Bacterial profile of surgical site infection and antimicrobial resistance patterns in Ethiopia : a multicentre prospective cross-sectional study. Ann Clin Microbiol Antimicrob. 2023 ; 22 :96. Lakoh S, Yi L, Russell JBW, Zhang J, Sevalie S, Zhao Y, et al. The burden of surgical site infections and related antibiotic resistance in two geographic regions of Sierra Leone : a prospective study. Ther Adv Infect Dis. 2022 ; 9: 1-15. Aiken AM, Wanyoro AK, Mwangi J, Juma F, Mugoya IK, Scott JAG. Changing use of surgical antibiotic prophylaxis in Thika Hospital, Kenya: a quality improvement intervention with an interrupted time series design. PLoS One. 2013;8:e78942. WHO. Protocol for surgical site infection surveillance with focus on settings with limited resources. 2018. http://www.who.int/infection prevention/tools/surgical/evaluation_feedback/en/ (accessed Feb 28, 2018). Korol E, Johnston K, Waser N, Sifakis F, Jafri HS, Lo M, et al. A systematic review of risk factors associated with surgical site infections among surgical patients. PloS One. 2013;8(12):e83743. GlobalSurg Collaborative. Determining the worldwide epidemiology of surgical site infections after gastrointestinal resection surgery: protocol for a multicentre, international, prospective cohort study (GlobalSurg 2). BMJ Open. 2017;7(7):e012150. Cruse PJ, Foord R. The epidemiology of wound infection. A 10-year prospective study of 62,939 wounds. Surg Clin North Am. 1980 ;60(1):27‑40. Farthouat P, Ogougbémy M, Million A, Sow A, Fall O, Dieng D et al. Infections du site opératoire (ISO) en chirurgie viscérale. Etude prospective à l’hôpital principal de Dakar. Médecine d’Afrique Noire. 2009; 56(3). Abdoulaye O, Harouna Amadou ML, Amadou O, Adakal O, Lawanou HM, Boubou L, et al. Aspects épidémiologiques et bactériologiques des infections du site opératoire (ISO) dans les services de chirurgie à l’Hôpital National de Niamey (HNN). Pan Afr Med J. 2018 ;31 :33. Mukagendaneza MJ, Munyaneza E, Muhawenayo E, Nyirasebura D, Abahuje E, Nyirigira J, et al. Incidence, root causes, and outcomes of surgical site infections in a tertiary care hospital in Rwanda: a prospective observational cohort study. Patient Saf Surg. 2019;13(1):10. Allegranzi B, et al. A multimodal infection control and patient safety intervention to reduce surgical site infections in Africa : a multicentre, before–after, cohort study. Lancet Infect Dis. 2018 ;18(5):507-15. Morrissey I, Hackel M, Badal R, Bouchillon S, Hawser S, Biedenbach D. A Review of Ten Years of the Study for Monitoring Antimicrobial Resistance Trends (SMART) from 2002 to 2011. Pharmaceuticals. 2013;6(11):1335. Yh C, Pr H. Changing bacteriology of abdominal and surgical sepsis. Curr Opin Infect Dis. 2012;25(5):590-5. Awad SS. Adherence to surgical care improvement project measures and post-operative surgical site infections. Surg Infect (Larchmt) . 2012;13(4):234-7. O’Brien WJ, Gupta K, Itani KMF. Association of postoperative infection with risk of long-term infection and mortality. JAMA Surg. 2020;155(1):61-68. Woeste MR, Cheadle WG. Postoperative Infection—A Pervasive Mediator of Patient Mortality. JAMA Surg. 2020;155(1):68. Global Alliance for Infections in Surgery Working Group. A Global Declaration on Appropriate Use of Antimicrobial Agents across theSurgical Pathway. Surg Infect (Larchmt) . 2017;18:846-53. Sartelli M, Coccolini F, Abu-Zidan FM, Ansaloni L, Bartoli S, Biffl W, et al. Hey surgeons! It is time to lead and be a champion in preventing and managing surgical infections! World J Emerg Surg. 2020 Apr 19;15(1):28. Tables Table I: Classification according to Altemeier classes and CDC-NHSN [1]) Altemeier class Number % Class 1 clean 7 12 Class 2 clean contaminated 32 54 Class 3 contaminated 17 29 Class 4 dirty/infected 3 5,1 Table II: Distribution of SSIs sites according to CDC [1] SSIs site Number % Superficiel incisional 48 81,3 Organ/space 6 12,2 Deep incisional 5 10,20 Total 59 100 Table III: Distribution of 44 germs founded from SSIs Germs identified Number % Enterobacteria 36 81.8 Escherichia coli 22 50 Klebsiella pneumoniae 6 13,6 Enterobacter cloacae 4 9 Enterobacter aerogenes 1 2,2 Enterobacter sp 1 2,2 Serratia marcescens 1 2,2 Proteus mirabilis 1 2,2 Aeromonas hydrophila 1 2,2 Non fermentative gram negative bacilli 7 16 Pseudomonas aeruginosa 5 11.3 Burkholderia cepacia 1 2.2 Acinetobacter baumanni 1 2.2 Total 44 Table IV: Distribution of bacteria according to resistance phenotypes of 44 pathogens Germs ESBL HCASE LL-PASE HL- PASE CarbASE Cefta-R ChromCASE Enterobacteria 22(50%) 5(11.3%) 3(6.8%) 2(4.5%) 3(6.8%) 1 (2.2%) Escherichia Coli 15 2 2 2 1 - - Klebsiella pneumoniae 4 1 1 - - Enterobacter cloacae - 2 - - 1 - 1 Enterobacter a. - - - - 1 - - Enterobacter spp. 1 - - - - - - Serratia marcescens 1 - - - - - - Proteus mirabilis 1 - - - - - - Aeromonas h. - - - - - 1(2.2%) - NFGN - - - - - 7 (16%) - Pseudomonas a. - - - - - 5 - Bulkholderia cepacia - - - - 1 - Acinobacter baumanni - - - - - 1 - Non-fermentative gram-negative (NFGN) Non-AMR phenotype: - Klebsiella p. Low level PASE (LL-PASE) - Enterobacter cloacae with chromosomal cephalosporinase (ChromPASE) Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6839562","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":484919410,"identity":"a972c3a1-206f-460e-96a4-b1606813051e","order_by":0,"name":"Magatte Faye","email":"","orcid":"","institution":"Military teaching hospital, Hôpital Principal Dakar","correspondingAuthor":false,"prefix":"","firstName":"Magatte","middleName":"","lastName":"Faye","suffix":""},{"id":484919412,"identity":"4308fb33-0f54-4509-9cbf-99b0a787461e","order_by":1,"name":"Moustapha Diop","email":"","orcid":"","institution":"Military teaching hospital, Hôpital Principal Dakar","correspondingAuthor":false,"prefix":"","firstName":"Moustapha","middleName":"","lastName":"Diop","suffix":""},{"id":484919415,"identity":"536f68cc-309b-47a5-a93e-aea3c871dd8a","order_by":2,"name":"Maguette ndoye","email":"","orcid":"","institution":"Military teaching hospital, Hôpital Principal Dakar","correspondingAuthor":false,"prefix":"","firstName":"Maguette","middleName":"","lastName":"ndoye","suffix":""},{"id":484919416,"identity":"01ba3acc-7f07-4739-b144-91cc650b5363","order_by":3,"name":"Birame Ndiaye","email":"","orcid":"","institution":"Military teaching hospital, Hôpital Principal Dakar","correspondingAuthor":false,"prefix":"","firstName":"Birame","middleName":"","lastName":"Ndiaye","suffix":""},{"id":484919417,"identity":"5a93169c-b5c6-4adb-bc56-9d2b70f116af","order_by":4,"name":"Abdourahmane Sané","email":"","orcid":"","institution":"Military teaching hospital, Hôpital Principal Dakar","correspondingAuthor":false,"prefix":"","firstName":"Abdourahmane","middleName":"","lastName":"Sané","suffix":""},{"id":484919418,"identity":"52c0136e-b1e9-4a37-9afc-fa903d41ee09","order_by":5,"name":"Babacar Niang","email":"","orcid":"","institution":"Military teaching hospital, Hôpital Principal Dakar","correspondingAuthor":false,"prefix":"","firstName":"Babacar","middleName":"","lastName":"Niang","suffix":""},{"id":484919419,"identity":"e7b8748f-e8a4-4dce-8071-b23428685f59","order_by":6,"name":"Sokhna Moumy Mbacké Daffé","email":"","orcid":"","institution":"Military teaching hospital, Hôpital Principal Dakar","correspondingAuthor":false,"prefix":"","firstName":"Sokhna","middleName":"Moumy Mbacké","lastName":"Daffé","suffix":""},{"id":484919420,"identity":"17824ace-c798-4d1b-9e02-bc2040508c13","order_by":7,"name":"Mamadou Wague Guèye","email":"","orcid":"","institution":"Military teaching hospital, Hôpital Principal Dakar","correspondingAuthor":false,"prefix":"","firstName":"Mamadou","middleName":"Wague","lastName":"Guèye","suffix":""},{"id":484919421,"identity":"1e72bdf6-ab47-4630-bb89-2d5a49f3811b","order_by":8,"name":"Madawase Mboup","email":"","orcid":"","institution":"Military teaching hospital, Hôpital Principal Dakar","correspondingAuthor":false,"prefix":"","firstName":"Madawase","middleName":"","lastName":"Mboup","suffix":""},{"id":484919422,"identity":"77b1ecfb-546e-4c85-a60c-39d96587fcfa","order_by":9,"name":"Mamadou Dembélé","email":"","orcid":"","institution":"Military teaching hospital, Hôpital Principal Dakar","correspondingAuthor":false,"prefix":"","firstName":"Mamadou","middleName":"","lastName":"Dembélé","suffix":""},{"id":484919423,"identity":"bff1b174-bead-4e5e-9c35-1a38bd974f64","order_by":10,"name":"Ndèye Seynabou Diop","email":"","orcid":"","institution":"Military teaching hospital, Hôpital Principal Dakar","correspondingAuthor":false,"prefix":"","firstName":"Ndèye","middleName":"Seynabou","lastName":"Diop","suffix":""},{"id":484919424,"identity":"9b129495-1d8a-43a4-8b6a-0934b780f77f","order_by":11,"name":"Mamadou Seck","email":"","orcid":"","institution":"Military teaching hospital, Hôpital Principal Dakar","correspondingAuthor":false,"prefix":"","firstName":"Mamadou","middleName":"","lastName":"Seck","suffix":""},{"id":484919425,"identity":"da75c387-1f89-4816-bc72-dc6e299e3ebb","order_by":12,"name":"Idrissa Guèye","email":"","orcid":"","institution":"Military teaching hospital, Hôpital Principal Dakar","correspondingAuthor":false,"prefix":"","firstName":"Idrissa","middleName":"","lastName":"Guèye","suffix":""},{"id":484919426,"identity":"b6d7ee88-2269-4ee5-b7b9-cac13e9a7a8e","order_by":13,"name":"Sokhna Diagne","email":"","orcid":"","institution":"Military teaching hospital, Hôpital Principal Dakar","correspondingAuthor":false,"prefix":"","firstName":"Sokhna","middleName":"","lastName":"Diagne","suffix":""},{"id":484919427,"identity":"42d630ac-e18b-4769-8a98-b7ee8e6b71a8","order_by":14,"name":"Ousmane Bianquinch","email":"","orcid":"","institution":"Military teaching hospital, Hôpital Principal Dakar","correspondingAuthor":false,"prefix":"","firstName":"Ousmane","middleName":"","lastName":"Bianquinch","suffix":""},{"id":484919428,"identity":"dca81262-bfd2-40ba-807c-cb9f60319ea1","order_by":15,"name":"Rodrigue Gomis","email":"","orcid":"","institution":"Military teaching hospital, Hôpital Principal Dakar","correspondingAuthor":false,"prefix":"","firstName":"Rodrigue","middleName":"","lastName":"Gomis","suffix":""},{"id":484919429,"identity":"5f3ca833-46d5-4ca2-a3cb-5e3c191d7728","order_by":16,"name":"Tracie Joyner Youbong","email":"","orcid":"","institution":"Military teaching hospital, Hôpital Principal Dakar","correspondingAuthor":false,"prefix":"","firstName":"Tracie","middleName":"Joyner","lastName":"Youbong","suffix":""},{"id":484919430,"identity":"e9fcc718-fbef-436b-98ee-9eee1292fb86","order_by":17,"name":"Pape Silmane Diawara","email":"","orcid":"","institution":"Military teaching hospital, Hôpital Principal Dakar","correspondingAuthor":false,"prefix":"","firstName":"Pape","middleName":"Silmane","lastName":"Diawara","suffix":""},{"id":484919431,"identity":"c0861fb1-4ad0-4bb2-8e89-5693d5727415","order_by":18,"name":"Bécaye Fall","email":"","orcid":"","institution":"Military teaching hospital, Hôpital Principal Dakar","correspondingAuthor":false,"prefix":"","firstName":"Bécaye","middleName":"","lastName":"Fall","suffix":""},{"id":484919432,"identity":"cff3985c-5ce3-48be-897e-fbcfe7a8f3d7","order_by":19,"name":"Pape Samba Ba","email":"","orcid":"","institution":"Military teaching hospital, Hôpital Principal Dakar","correspondingAuthor":false,"prefix":"","firstName":"Pape","middleName":"Samba","lastName":"Ba","suffix":""},{"id":484919433,"identity":"1372638b-a2c2-497e-9217-94828b39d8d9","order_by":20,"name":"Madjiguène Koné","email":"","orcid":"","institution":"Military teaching hospital, Hôpital Principal Dakar","correspondingAuthor":false,"prefix":"","firstName":"Madjiguène","middleName":"","lastName":"Koné","suffix":""},{"id":484919434,"identity":"bbd30853-a2fd-4d40-8525-ac5685a12e39","order_by":21,"name":"Mouhamadou Mansour Fall","email":"","orcid":"","institution":"Military teaching hospital, Hôpital Principal Dakar","correspondingAuthor":false,"prefix":"","firstName":"Mouhamadou","middleName":"Mansour","lastName":"Fall","suffix":""},{"id":484919435,"identity":"80343b7c-14a5-495b-9ee2-3c8148d99d5c","order_by":22,"name":"Ibrahima Sall","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyUlEQVRIiWNgGAWjYFAC5sYDDAYS9f0MDGwgLj8RWhgbgFosGGc2QLRINhCnhaGCccMBYrXItx8EaimQYDa+kfzswYcKBglzQnoMziSCHCbBZnYjzdxwxhkGCZkDhLQwQLTwmN1IMJPmbWOokyDosP6HYC0SxjPSv4G0SBDUwnADYouBgUSOGXFaDG5AbEmQOPOmTHLGGQnCWuT7kw8+YPhTl8Dfnr5N4kOFDREOAwLmPyBSIAFEEqUBBvgPkKJ6FIyCUTAKRhIAAG8tO+97YL8hAAAAAElFTkSuQmCC","orcid":"","institution":"Military teaching hospital, Hôpital Principal Dakar","correspondingAuthor":true,"prefix":"","firstName":"Ibrahima","middleName":"","lastName":"Sall","suffix":""},{"id":484919437,"identity":"1765cdaf-7ef8-4678-acc5-13ed9c5ecc21","order_by":23,"name":"Eugène Diémé","email":"","orcid":"","institution":"Military teaching hospital, Hôpital Principal Dakar","correspondingAuthor":false,"prefix":"","firstName":"Eugène","middleName":"","lastName":"Diémé","suffix":""},{"id":484919439,"identity":"3af3d643-88ee-4049-ab05-cc47f573765a","order_by":24,"name":"Omar Fall","email":"","orcid":"","institution":"Military teaching hospital, Hôpital Principal Dakar","correspondingAuthor":false,"prefix":"","firstName":"Omar","middleName":"","lastName":"Fall","suffix":""},{"id":484919442,"identity":"f5175685-8cf8-41b1-937b-da6d3312dd01","order_by":25,"name":"Alamasso Sow","email":"","orcid":"","institution":"Military teaching hospital, Hôpital Principal Dakar","correspondingAuthor":false,"prefix":"","firstName":"Alamasso","middleName":"","lastName":"Sow","suffix":""}],"badges":[],"createdAt":"2025-06-06 21:23:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6839562/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6839562/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":99316665,"identity":"81253a05-0a6a-4661-b0cc-8d8f3968fee8","added_by":"auto","created_at":"2025-12-31 16:28:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1158489,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6839562/v1/86b428d7-d191-4dce-a8ae-e708e0855622.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Profile and impact of antimicrobial resistance related to surgical site infections after abdominal surgery in a resource-limited country: a prospective observational cohort study","fulltext":[{"header":"Background","content":"\u003cp\u003eSurgical site infections (SSIs) remain a substantial cause of morbidity, accounting for 25% of\u003c/p\u003e\u003cp\u003eHospital acquired infections (HAIs). SSIs is a major cause of hospital mortality, increasing to a factor 10 the risk of death. SSI is the most costly HAI type ; and increase hospital length of stay by 9.7 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In addition to this, they also have a significant quality of life and economic impact on the population and society [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe global incidence of surgical site infections (SSIs) is estimated by WHO between 3\u0026ndash;50%, depending on the type of surgery, and is particularly high in low- and middle-income countries (LMICs), where SSIs are the most frequently reported healthcare-associated infection (HAI) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAntimicrobial resistance (AMR) poses a societal-level hazard, with an estimated 1.27\u0026nbsp;million deaths attributable to bacterial AR globally in 2019 [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Escherichia coli (E. coli) and Staphylococcus aureus, the two leading pathogens for deaths associated with antibacterial resistance, are also the two most prevalent bacterial species isolated from postoperative infections [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Contracting SSI increases antibiotic use seven-fold [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Because of AMR, the miracle impact of antibiotics to reduce infectious morbidity in surgery is rapidly waning; so, the prevention and surveillance of SSIs is absolutely necessary.\u003c/p\u003e\u003cp\u003eA one-year prospective observational cohort study on Surgical site infections (SSIs) after abdominal surgery is being conducted in our surgical department; with the the aim to figure out incidence, root causes, outcomes and to foster a sustainable surveillance system with collaborating physicians of infectious diseases, anesthesiologists, and biologists. Considering the amount of AMR in preliminary checking, we thought to study its profile and impact on outcomes; in order to guide SSIs management and antibiotic stewardship.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design\u003c/h2\u003e\u003cp\u003eThis prospective observational cohort study is being conducted in the department of visceral surgery since February 1, 2024. Our hospital is a level 4 military teaching hospital in Senegal, West Africa, a Low-middle income country (LMIC); with an estimated population of 18\u0026nbsp;million in 2023. The level 4, according to United Nations (UN) definition based on the treatment capabilities and capacity of a medical unit, offers highly specialized care, including intensive care, trauma surgery, and advanced diagnostic services. WHO Protocol for surgical site infection surveillance with focus on settings with limited resources [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] is used to select and compile parameters of study.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eOperational definitions\u003c/h3\u003e\n\u003cp\u003eSurgical site infection occurs near or at the incision site and/or deeper underlying tissue spaces and organs within 30 days of a surgical procedure performed (or up to 90 days for implanted prosthetics) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Assessment of the degree of contamination of a surgical wound at the time of the surgical procedure is based on four wound classifications: Clean (class 1), Clean-Contaminated (class 2), Contaminated (class 3), and Dirty/Infected (class 4) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Multidrug resistance (MDR) refers to resistance at least one antimicrobial agent in three or more antimicrobial classes. Antibioprophylaxis was systematic according to standard of care and to our antibiotic stewardship. After surgery antibiotics were administered in class 3 for 2 days hours; and in class 4 for 5 days.\u003c/p\u003e\u003cp\u003eDiagnosis of SSIs was made according to CDC (Center for disease control and prevention) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] criterion and classified: Superficial incisional (SI); Deep Incisional (DI) and Organ/Space (OS).\u003c/p\u003e\u003cp\u003eTrained personnel collected SSIs samples (pus or serosities), aseptically (sterile syringe or sterile cotton-tipped swabs from inside to outside). Antibiotics for SSIs was indicated in face of proof of SSIs and systemic inflammatory response syndrome or sepsis.\u003c/p\u003e\n\u003ch3\u003ePatient recruitment\u003c/h3\u003e\n\u003cp\u003eOver 8 months (February 1, 2024-September 31, 2024), we included all patients aged over 15 years who had abdominal (digestive or parietal) elective or emergency surgery. Consent was acquired for all patients, and parental consent for patients under 15 years old. Patients who developed signs and symptoms of SSI and given consent for the follow up were enrolled. Decision to identify eligible patients as SSI cases were done by attending physicians. All patients were followed up even upon discharge and those who presented a SSI within 30 days, 90 days in the case of a prosthesis were identified. We did not include patients who died in less than 15 days and those who had proctological, gynecological or urological pathology.\u003c/p\u003e\n\u003ch3\u003eSSIs Sampling\u003c/h3\u003e\n\u003cp\u003eWhen the suppuration was deep (fascia / muscle) or organ (postoperative or persistent peritonitis) the pus was collected using a syringe which was at once sent to the laboratory.\u003c/p\u003e\u003cp\u003eFor superficial suppurations (fascia, subcutaneous cellular tissue), samples were taken using a syringe if the suppuration was abundant or by swabbing if it was minimal after disinfection of the surgical wound.\u003c/p\u003e\n\u003ch3\u003eData and parameters collection\u003c/h3\u003e\n\u003cp\u003eDatas were compiled according to the WHO Protocol for surgical site infection surveillance with focus on settings with limited resources [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Parameters included: incidence of SSIs, clinical characteristics, preoperative, operative and post operative data related to SSIs, previous antibiotic therapy, bacteria and their phenotype of resistance, outcomes and mortality. Bacteriological results were collected from the laboratory after assessment of attending biologists. Resistance phenotypes were classified by:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eExtended spectrum beta lactamase (ESBL)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eLow-level penicillinase (LL-PASE)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eHigh-level penicillinase (HL-PASE)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eHypersecretion of cephalosporinase (HCASE)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eCarbapenemase (CarbASE)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eCeftacidim-Resistant (Cefta-R)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eChromosomal cephalosporinase (ChromCASE)\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eData management and statistical analysis\u003c/h2\u003e\u003cp\u003eData were included anonymously on \u0026laquo; kobocollect \u0026raquo; website (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://kf.kobotoolbox.org\u003c/span\u003e\u003cspan address=\"https://kf.kobotoolbox.org\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) and exported to an Excel file and then analyzed using version 4.3.3 of the R software. According to their distribution, quantitative variables were represented using either means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviations (SD) or medians and their extremes (IQR). Qualitative variables were represented using frequency and percentages.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003ePeri-operative characteristics\u003c/h2\u003e\u003cp\u003eWe collected 328 patients; the surgical site infection (SSI) rate was 17.9% (n\u0026thinsp;=\u0026thinsp;59). The mean age of patients who presented with SSI was 51 years; there were 28 women and 31 men (sex ratio 1.1).\u003c/p\u003e\u003cp\u003eMost patients who had SSI were classified ASA 1 (53%) and had an emergency operation (88.1%). Surgical interventions were class 2 in 54% of cases (Table I). All our patients had received antibiotic prophylaxis or therapy according to the Altemeier class and to the surgical diagnosis. The most used antibiotic for prophylaxis was cefazolin (54.8%); ampicillin 22.5%, amoxicilline-clavunate (11.6%).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eSSIs characteristics\u003c/h2\u003e\u003cp\u003eThe mean time to occurrence of SSIs was 9 days and presented as purulent wound discharge in 71% (n\u0026thinsp;=\u0026thinsp;42) of cases. The SSIs was Superficial incisional (SI) in 81.3% (n\u0026thinsp;=\u0026thinsp;48); Deep incisional (DI) in 8.4% (n\u0026thinsp;=\u0026thinsp;5) and Organ/space (OS) in 10.1% (n\u0026thinsp;=\u0026thinsp;6) (Table II).\u003c/p\u003e\u003cp\u003eAmong patients with ISO, 60.8% were already on antibiotics according to surgical diagnosis; ceftriaxone-metronidazole combination was given for the most patients (49.2%).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eMicrobiology\u003c/h2\u003e\u003cp\u003eBacteria were identified for 37 patients (62.7%), with 44 germs found (Table III). Sample was mono-microbial in 83.7% of patients (n\u0026thinsp;=\u0026thinsp;31), bi-microbial (13.5% \u0026minus;\u0026thinsp;5 patients) and tri-microbial (2.7% \u0026minus;\u0026thinsp;1patient). The most common bacteria were Enterobacteria in 81.8% (n\u0026thinsp;=\u0026thinsp;36/44) of cases; with E. coli in the lead (50% of 44), followed by Klebsiella pneumoniae (13.6% of 44) and Enterobacter cloacae (9% of 44). Non-fermentative Gram-negative bacilli were noted in 7 patients (16% of 44); with Pseudomonas aeruginosa in 5 patients. Aeromonas hydrophila was found in 1 sample (2.2%).\u003c/p\u003e\u003cp\u003eAMR phenotype was found in 95.4% (42/44) of bacteria specimens (Table IV). The resistance phenotype within Enterobacteria was 94.6% (35/36); with ESBL in 50% of cases, followed by HCASE in 11.3% and then PASE in 11.3%. Among the non-fermentative gram-negative (NFGN) bacilli, in particular for Pseudomonas aeruginosa, the Ceftacidim-Resistant phenotype was noted for all (100%).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eTreatment and outcomes\u003c/h2\u003e\u003cp\u003eSSIs were treated by wound care for the most (86.4%, n\u0026thinsp;=\u0026thinsp;51) in bed hospital and after discharge. Negative pressure therapy (NPT) was indicated for 5 (8.4%); 2 DI and 3 OS. Surgery was indicated for 3 patients (5%); 1 DI and 2 OS. Antibiotic therapy was indicated for 5 patients (8.4%); 1 DI and 4 OS. Antibiotic therapy was used in addition to 3 surgeries and 2 NPT. The antibiotic molecule according to resistance phenotype was vancomycin in combination with imipenem (2 patients), piperacilline-tazobactam (1patient), amoxicillin-clavunate (1patient) and ceftriaxone\u0026thinsp;+\u0026thinsp;metronidazol. The overall mortality was 10.1% (n\u0026thinsp;=\u0026thinsp;6). One SI SSIs death is related to pulmonary embolism. Two DI SSIs deaths are related to septic shock. Three OS SSIs deaths are related to septic shock (n\u0026thinsp;=\u0026thinsp;2) and Gastrointestinal bleeding (n\u0026thinsp;=\u0026thinsp;1). Organ/Space SSIs are related to surgical complications (anastomotic leakage). The main cause of death was septic shock (4 patients/6\u0026ndash;66%) related to blood stream contamination with Multidrug resistance (MDR) bacteria.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eIncidence of SSIs\u003c/h2\u003e\u003cp\u003eThe incidence of SSI varies from 0.1 to 50.4% depending on surgical specialties and countries [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In digestive surgery, a multicenter study (Globalsurg 2) including several countries with different incomes studying the rate of SSI after gastrointestinal resection demonstrated an incidence of SSI that varied significantly according to the human development index (HDI) with SSI rates inversely proportional to the HDI: high HDI (9.45% SSI), medium HDI (14.0% SSI) and low HDI (23.2% SSI) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Our SSI rate of 17.9% is slightly lower compared to other countries with a low HDI; in fact, we had included in our series all patients of abdominal surgery (with or without gastrointestinal resection); knowing that patients having an intestinal resection (Altemeier class\u0026thinsp;\u0026gt;\u0026thinsp;1) have a higher risk of having an ISO [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Fartouah et al had noted an incidence of 5.1% in a study carried out in the same department in 2004 [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This low incidence was explained by the fact that patients who had an SSIs after their discharge were not taken into account.\u003c/p\u003e\u003cp\u003eMany studies, as other African series, are not comparable because of heterogeneity of patients and study design with incidence of SSIs between 10% and 30% [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The fact is that SSIs incidence is too high in LMICs, despite existing proof of efficient preventive measures and multimodal strategies to control the burden [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. One reality for us is that Superficial incisional SSIs are predominant suggesting insufficiency in surgical wound management, lack of wound protector for open surgeries and low practice of minimal invasive surgery for contaminated classes.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eMicrobiology and Resistance phenotype\u003c/h2\u003e\u003cp\u003eThe type of germ isolated in SSIs varies according to the infectious flora; Gram-positive cocci (Staphyloccoccus aureus, Coagulase-negative Staphylococcus) are more often noted in SSIs after clean surgery (orthopedics and cardiac surgery). Enterobacteria (E. coli, Enteroccocus sp\u0026hellip;) are founded after digestive contaminated surgery [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Because of abdominal surgical site in our department, Enterobacteria were the most isolated germs founded (84%). The absence of staphylococcus is a good point, fostering our practice of hygiene in the operating rooms.\u003c/p\u003e\u003cp\u003eSSIs are often poly-microbial with anaerobic and aerobic microorganisms. This poly-microbial etiology is more important in visceral surgery with a rate of 40% during contaminated surgery [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The poly-microbial sampling rate is lower in our study (23%), but we did not consider yet to analyze different classes of contamination.\u003c/p\u003e\u003cp\u003eThe prevalence of Enterobacteria producing ESBL has increased worldwide [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The prevalence of Enterobacteria producing ESBL in patients with intra-abdominal infection is increasing over time in Asia, Europe, Latin America, the Middle East, North America and the South Pacific; in Africa this prevalence has been estimated to 10% in 2013 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. When looking at our cohort of SSIs, AMR resistance phenotype concern almost all cases (42/44\u0026ndash;94.5%); with 50% of ESBL found for Enterobacteria and 100% of Ceftacidim-Resistant for NFGN bacilli. This observation shows that occurrence of SSIs is related to occurrence of AMR phenotype. SSIs and AMR are twin's threats.\u003c/p\u003e\u003cp\u003eAlso, antibiotic therapy does not prevent the occurrence of SSIs, considering 60.8% of our patients which were earlier on antibiotics with no sensibility on SSIs bacteria specimens.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eTreatment and outcomes\u003c/h2\u003e\u003cp\u003eDespite the virulence of certain isolated pathogens, only 5 patients benefited from targeted antibiotic therapy in addition to surgery or drainage because they presented signs of sepsis. Wound care of the surgical incision, conservative treatment for leaks in surgical drainage orifices and NPT were enough to achieve clinal improvement for the most. Antibiotics are not mandatory for SSIs in the absence of sepsis. The risk of mortality is less related to post-operative complications (anastomotic leakage, pulmonary embolism, bleeding), but is increased by AMR and MDR contamination. The mortality rate associated with these infections average is 3\u0026ndash;5% (10.1% for us), and 75% of those deaths are directly attributable to the SSI [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn a recent large retrospective cohort from 203 to 2008 [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], the consequences of post-operative infection (including SSIs), was precisely studied. Infection in the 30-day period following surgery leads to a significantly higher risk of infection and mortality in the subsequent year (hazardratio, 3.17; 95% CI, 3.05\u0026ndash;3.28 and hazardratio,1.89 ; 95% CI, 1.79\u0026ndash;1.99, respectively). Overall, 24810 patients (3.8%) died during follow-up. Observed mortality rate in those in the exposure group was 12.9% (3067 of 23815) compared with 3.4% (21743 of 635671) in the control group. \u0026laquo; Post-operative infection is a pervasive mediator of patient mortality \u0026raquo; [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIt is fundamental for health care workers : to understand the extent of the consequences of SSIs ; to increase their knowledge and motivation ; to implement precautions, and take prevention recommendations very seriously [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Early recognition is also of extreme importance to quickly manage SSIs before they progress to serious complications ; for that multidisciplinary collaboration is crucial. Improving patient safety in today\u0026rsquo;s hospitals worldwide requires a systematic approach to combat AMR and to prevent and treat infections appropriately. The two concepts go hand-in-hand [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. AMR has emerged as one of the major public health problems of the twenty-first century [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Definitly, this preliminary results is a real life portrait and awareness, that will be the factual beginning of our commitment against SSIs.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eThis preliminary descriptive study does not consider cost and length of stay related to SSIs. Digestive and non-digestive surgeries are not separately extracted for this study. The project is not achieved yet but give us real-life orientations to adapt SSIs prevention and management.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe incidence of SSIs in our context is 17.9%. This study allowed us to know the local ecology of pathogens after SSIs, and the scientific knowledge to improve our practice. SSIs and AMR are twin's threats. Antibiotics therapy is not mandatory for SSIs, highlighting the role of the surgeon in the earlier diagnosis and multimodal management of these infections. In fact, SSIs contribute to occurrence of AMR phenotype and MDR bacteria. The main cause of death related to bloodstream nosocomial MDR infections, shows that SSIs increase the length of stay and the risk of nosocomial infection with MDR bacteria. In our context, improving surgical wound protection, efficient antibiotic stewardship, collaboration of physicians and implementing an integrated strategy with involved physicians, will reduce SSIs and avoid AMR for a sustainable and safe surgical practice.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAntimicrobial resistance (AMR)\u003c/p\u003e\n\u003cp\u003eMultidrug resistance (MDR)\u003c/p\u003e\n\u003cp\u003ePseudomans aeroginosa (Pseudomonas a.)\u003c/p\u003e\n\u003cp\u003eEnterobacter aerogenes (Enterobacter a.)\u003c/p\u003e\n\u003cp\u003eEscherichia Coli (E. coli)\u003c/p\u003e\n\u003cp\u003eNon-fermentative gram-negative bacilli (NFGN bacilli)\u003c/p\u003e\n\u003cp\u003eAeromonas hydrophila (Aeromonas h.)\u003c/p\u003e\n\u003cp\u003eExtended-spectrum beta lactamase (ESBL)\u003c/p\u003e\n\u003cp\u003eLow-level penicillinase (LL-PASE)\u003c/p\u003e\n\u003cp\u003eHigh-level penicillinase (HL-PASE)\u003c/p\u003e\n\u003cp\u003eHypersecretion of cephalosporinase (HCASE)\u003c/p\u003e\n\u003cp\u003eCarbapenemase (CarbASE)\u003c/p\u003e\n\u003cp\u003eCeftacidim-Resistant (Cefta-R)\u003c/p\u003e\n\u003cp\u003eChromosomal cephalosporinase (ChromCASE)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eClinical trial number \u003c/strong\u003e: not applicable\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding is available yet.\u003c/p\u003e\n\n\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFaye M, Diop M, Di\u0026eacute;m\u0026eacute; E and Sall I were principal researchers and conceived the study; with data collection, analysis, interpretation of the findings, drafting the manuscript, and write-up. All authors took part to manuscript conception and provided critical intellectual content. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank physicians, nurses, and microbiologists from all the study sites who helped us undertake this study. Lastly, our gratitude goes to all the study participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResearch data supporting the findings of this study have been compiled in our department. All necessary data is provided within the manuscript. The data sets generated during and/or analyzed during the current study are available from the corresponding authors on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval was obtained from local ethics committee of the Military Teaching Hospital. Data were collected after full informed and written consent or assent was obtained from each participant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declare that they have no competing interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eSurgical Site Infection Event (SSI). Center for Disease Control and Prevention (CDC). National Healthcare Safety Network (NHSN). 2023. https://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual current.pdf. (Accessed 09 oct 2024). \u003c/li\u003e\n \u003cli\u003eAllegranzi B, et al. Burden of endemic health-care-associated infection in developing countries : systematic review and meta-analysis. Lancet. 2011;377(9761):228–41.\u003c/li\u003e\n \u003cli\u003eLermite É, Christou N, Baillet P. Infections du site opératoire : rapport présenté au 122e Congrès français de chirurgie, Paris, 2-4 septembre 2020. Monographies de l’Association française de chirurgie. Arcueil : Arnette ; 2020. \u003c/li\u003e\n \u003cli\u003eGlobal Guidelines for the Prevention of Surgical Site Infection [Internet]. Geneva : World Health Organization, 2018. http.www.ncbi.nlm.nih.gov/books/NBK536404/. (Accessed 15 oct 2023).\u003c/li\u003e\n \u003cli\u003eMurray CJ, Ikuta KS, Sharara F, Swetschinski L, Robles Aguilar G, Gray A et al. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet. 2022; 399:629–655.\u003c/li\u003e\n \u003cli\u003eBirgand G, Dhar P, Holmes A. The threat of antimicrobial resistance in surgical care: the surgeon’s role and ownership of antimicrobial stewardship. BJS. 2023; 110:1567–1569.\u003c/li\u003e\n \u003cli\u003eWorku S, Abebe T, Alemu A, Seyoum B, Swedberg G, Abdissa A, et al. Bacterial profile of surgical site infection and antimicrobial resistance patterns in Ethiopia : a multicentre prospective cross-sectional study. Ann Clin Microbiol Antimicrob. 2023 ; 22 :96.\u003c/li\u003e\n \u003cli\u003eLakoh S, Yi L, Russell JBW, Zhang J, Sevalie S, Zhao Y, et al. The burden of surgical site infections and related antibiotic resistance in two geographic regions of Sierra Leone : a prospective study. Ther Adv Infect Dis. 2022 ; 9: 1-15.\u003c/li\u003e\n \u003cli\u003eAiken AM, Wanyoro AK, Mwangi J, Juma F, Mugoya IK, Scott JAG. Changing use of surgical antibiotic prophylaxis in Thika Hospital, Kenya: a quality improvement intervention with an interrupted time series design. PLoS One. 2013;8:e78942.\u003c/li\u003e\n \u003cli\u003eWHO. Protocol for surgical site infection surveillance with focus on settings with limited resources. 2018. http://www.who.int/infection prevention/tools/surgical/evaluation_feedback/en/ (accessed Feb 28, 2018).\u003c/li\u003e\n \u003cli\u003eKorol E, Johnston K, Waser N, Sifakis F, Jafri HS, Lo M, et al. A systematic review of risk factors associated with surgical site infections among surgical patients. PloS One. 2013;8(12):e83743. \u003c/li\u003e\n \u003cli\u003eGlobalSurg Collaborative. Determining the worldwide epidemiology of surgical site infections after gastrointestinal resection surgery: protocol for a multicentre, international, prospective cohort study (GlobalSurg 2). BMJ Open. 2017;7(7):e012150. \u003c/li\u003e\n \u003cli\u003eCruse PJ, Foord R. The epidemiology of wound infection. A 10-year prospective study of 62,939 wounds. Surg Clin North Am. 1980 ;60(1):27‑40. \u003c/li\u003e\n \u003cli\u003eFarthouat P, Ogougbémy M, Million A, Sow A, Fall O, Dieng D et al. Infections du site opératoire (ISO) en chirurgie viscérale. Etude prospective à l’hôpital principal de Dakar. Médecine d’Afrique Noire. 2009; 56(3).\u003c/li\u003e\n \u003cli\u003eAbdoulaye O, Harouna Amadou ML, Amadou O, Adakal O, Lawanou HM, Boubou L, et al. Aspects épidémiologiques et bactériologiques des infections du site opératoire (ISO) dans les services de chirurgie à l’Hôpital National de Niamey (HNN). Pan Afr Med J. 2018 ;31 :33.\u003c/li\u003e\n \u003cli\u003eMukagendaneza MJ, Munyaneza E, Muhawenayo E, Nyirasebura D, Abahuje E, Nyirigira J, et al. Incidence, root causes, and outcomes of surgical site infections in a tertiary care hospital in Rwanda: a prospective observational cohort study. Patient Saf Surg. 2019;13(1):10. \u003c/li\u003e\n \u003cli\u003eAllegranzi B, et al. A multimodal infection control and patient safety intervention to reduce surgical site infections in Africa : a multicentre, before–after, cohort study. Lancet Infect Dis. 2018 ;18(5):507-15.\u003c/li\u003e\n \u003cli\u003eMorrissey I, Hackel M, Badal R, Bouchillon S, Hawser S, Biedenbach D. A Review of Ten Years of the Study for Monitoring Antimicrobial Resistance Trends (SMART) from 2002 to 2011. Pharmaceuticals. 2013;6(11):1335. \u003c/li\u003e\n \u003cli\u003eYh C, Pr H. Changing bacteriology of abdominal and surgical sepsis. Curr Opin Infect Dis. 2012;25(5):590-5.\u003c/li\u003e\n \u003cli\u003eAwad SS. Adherence to surgical care improvement project measures and post-operative surgical site infections. \u003cem\u003eSurg Infect (Larchmt)\u003c/em\u003e. 2012;13(4):234-7. \u003c/li\u003e\n \u003cli\u003eO’Brien WJ, Gupta K, Itani KMF. Association of postoperative infection with risk of long-term infection and mortality. \u003cem\u003eJAMA Surg.\u003c/em\u003e 2020;155(1):61-68.\u003c/li\u003e\n \u003cli\u003eWoeste MR, Cheadle WG. Postoperative Infection—A Pervasive Mediator of Patient Mortality. \u003cem\u003eJAMA Surg. \u003c/em\u003e2020;155(1):68.\u003c/li\u003e\n \u003cli\u003eGlobal Alliance for Infections in Surgery Working Group. A Global Declaration on Appropriate Use of Antimicrobial Agents across theSurgical Pathway. \u003cem\u003eSurg Infect (Larchmt)\u003c/em\u003e. 2017;18:846-53.\u003c/li\u003e\n \u003cli\u003eSartelli M, Coccolini F, Abu-Zidan FM, Ansaloni L, Bartoli S, Biffl W, et al. Hey surgeons! It is time to lead and be a champion in preventing and managing surgical infections! \u003cem\u003eWorld J Emerg Surg. \u003c/em\u003e2020 Apr 19;15(1):28.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable I: Classification according to Altemeier classes and CDC-NHSN [1])\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAltemeier class\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eClass 1 clean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eClass 2 clean contaminated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eClass 3 contaminated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eClass 4 dirty/infected\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e5,1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eTable II: Distribution of SSIs sites according to CDC [1]\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSSIs site\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eNumber\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003eSuperficiel incisional\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28px;\"\u003e\n \u003cp\u003e81,3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003eOrgan/space\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28px;\"\u003e\n \u003cp\u003e12,2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003eDeep incisional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28px;\"\u003e\n \u003cp\u003e10,20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003eTotal\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28px;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable III: Distribution of 44 germs founded from SSIs\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGerms identified\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eEnterobacteria\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e81.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cem\u003eEscherichia coli\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e13,6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cem\u003eEnterobacter cloacae\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cem\u003eEnterobacter aerogenes\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e2,2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cem\u003eEnterobacter sp\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e2,2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cem\u003eSerratia marcescens\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e2,2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cem\u003eProteus mirabilis\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e2,2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eAeromonas hydrophila\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e2,2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eNon fermentative gram negative bacilli\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e11.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cem\u003eBurkholderia cepacia\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cem\u003eAcinetobacter baumanni\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e44\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eTable IV: Distribution of bacteria according to resistance phenotypes of 44 pathogens\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGerms\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eESBL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHCASE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLL-PASE \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHL- PASE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCarbASE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCefta-R\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eChromCASE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEnterobacteria\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e22(50%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e5(11.3%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e3(6.8%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e2(4.5%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e3(6.8%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e1 (2.2%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eEscherichia Coli\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; -\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp;-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eEnterobacter cloacae\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eEnterobacter a.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eEnterobacter spp.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eSerratia marcescens\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eProteus mirabilis\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eAeromonas h.\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e1(2.2%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNFGN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e7 (16%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePseudomonas a.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eBulkholderia cepacia\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eAcinobacter baumanni\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;Non-fermentative gram-negative (NFGN) \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Non-AMR phenotype:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp;- \u0026nbsp; \u0026nbsp; \u0026nbsp;Klebsiella p. Low level PASE (LL-PASE)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp;- \u0026nbsp; \u0026nbsp;Enterobacter cloacae with chromosomal cephalosporinase (ChromPASE)\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"abdominal surgery, antimicrobial resistance, low resource settings, Extended-spectrum beta-lactamase, surgical safety, surgical site infections","lastPublishedDoi":"10.21203/rs.3.rs-6839562/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6839562/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSurgical site infections (SSIs) are a major threat of safe surgical care. A one-year prospective observational cohort study on SSIs after abdominal surgery is being conducted in our department of surgery; with the goal to figure out the incidence, root causes, outcomes, and surveillance. Considering the amount of antimicrobial resistance (AMR) in SSIs, we thought to study its profile and impact on outcomes; in order to guide SSIs management and antibiotic stewardship.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter 8 months of this prospective observational cohort study (February 1, 2024-September 31, 2024), all patients above 15 years-old who had undergone surgical intervention in abdominal (digestive and parietal) surgery were included. The variable of interest, for this study, was the occurrence of SSI as well as its clinical and bacteriological characteristics, the antibiotic resistance phenotype, and outcomes. The WHO Protocol for surgical site infection surveillance with focus on settings with limited resources is used to compile parameters.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study involved 328 patients; the incidence of SSIs was 17.9% (n = 59). The mean age of patients with SSIs was 51 years and the sex ratio was 1.1. The SSIs was Superficial incisional (SI) in 81.3% (n=48); Deep incisional (DI) in 8.4% (n=5) and Organ/space (OS) in 10.1 % (n=6). Bacteria were identified for 37 patients (62.7%), with 44 germs found. The most common bacteria were Enterobacteria in 81.8% (n=36) of cases with Escherichia coli in the lead (50% of 44), followed by Klebsiella pneumoniae (13.6% of 44) and Enterobacter Cloacae (9% of 44). Non-fermentative Gram-negative bacilli were noted in 7 patients (16%); with Pseudomonas aeruginosa in 5 patients. 95.4 % (42/44) of bacteria were found to have AR phenotype. The resistance phenotype within Enterobacteria was Extended-spectrum beta-lactamase (ESBL) in 50% of cases, followed by Hypersecretion of cephalosporinase (HCASE) in 11.3% and then Penicillinase (PASE) in 11.3%. Among the non-fermentative gram-negative bacilli, in particular for Pseudomonas aeruginosa, the Ceftacidim-Resistant phenotype was noted for all (100%).\u003c/p\u003e\n\u003cp\u003eSSIs were treated by wound care for the most (86.4%, n=51). Antibiotics were indicated for 5 patients (8.4%),1 DI and 4 OS. Surgery was indicated for 3 patients (5%), 1 DI and 2 OS. Negative pressure therapy was indicated for 5 (8.4%), 2 DI and 3 OS. The overall mortality was 10.1% (n=6). The main cause of death was septic shock related blood stream contamination with Multidrug resistance (MDR) bacteria.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEnterobacteria were the most founded germs; with a predominantly ESBL resistance phenotype. SSIs and AMR are twin's threats. Antibiotics were not mandatory for SSIs treatment. In fact, SSIs contribute to occurrence of AMR phenotype and MDR bacteria. The main cause of death related to bloodstream nosocomial MDR infections, shows that SSIs increase the length of stay and the risk of nosocomial infection with MDR bacteria. In our context, improving surgical wound management, antibiotic stewardship, multidisciplinary collaboration, and multimodal prevention strategies will reduce SSIs and avoid AMR for a sustainable and safe surgical practice.\u003c/p\u003e","manuscriptTitle":"Profile and impact of antimicrobial resistance related to surgical site infections after abdominal surgery in a resource-limited country: a prospective observational cohort study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-15 16:57:55","doi":"10.21203/rs.3.rs-6839562/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"dfa2532b-7625-472b-aec6-c078110132b4","owner":[],"postedDate":"July 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-29T15:39:21+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-15 16:57:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6839562","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6839562","identity":"rs-6839562","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}