In the present study, the median age of SSIs was about 44 and most of them were males (73.26%). About 2.47% of cases died due to orthopedic surgical site infection. These results are in line with other literatures in which SSI was more among males and middle-aged patients with fatality rate of 2–3%. However, Al-Mulhim, et al found that SSI was more common in younger patients with an average age of 38 in Saudi Arabia. (16, 17)
Surgical site infection may lead to many complications, among which one is prolonged hospitalization due to infection. In this study, the median days of hospitalization due to orthopedic surgery was 17 days while the median length of hospitalization due to SSI was 11 days. This finding is similar to other prior studies that reported the mean of hospitalization days due to SSI; it varied from 4 to 32 days and the average length of increased hospitalization due to orthopedic SSIs was 19.8 days while the average length of stay for patients with no post-surgical infection was lower at 9.1 days (18–20). Thus, SSI can increase the economic and psychological burden on patients. It is Important to recognize the risk of being infected among patients using risk assessment and to follow nosocomial infection prevention protocols in surveillance system. In this study, a statistically significant association was found between the type of microorganisms with the occurrence of SSIs in post- discharge or pre-discharge time. In addition, the average time interval between surgery to the incidence of infection has been significantly longer among post-discharge SSIs; this could occur due to different incubation and infectious periods among a variety of microorganisms and the effect on the appearance of infection symptoms after surgery (21). However, the length of time between infection occurrence and its detection may be delayed because of the immune system response, consumption of prophylaxis, and being unaware of the infection symptoms.
After study on post- discharge and pre-discharge SSIs, it was observed that 76.24% of SSIs occurred after discharge, among which 45.54% occurred within 31 days after orthopedic procedure and, totally, 17.82% of SSIs were detected within 90 days to one year after orthopedic surgery. This varies by the type of orthopedic procedures. So that, 19.57% of SSIs due to ORIF procedures occurred post-discharge within 90 days to one year after surgery. These results were in line with other studies in which it was reported that the length of time between discharges to the detection of orthopedic SSIs varied between 8 days to 8 months. In another study, it was reported that most SSIs were detected after the 21st postoperative day (22, 23). As a result, this fact shows the importance of post-discharge surveillance, especially in procedures in which mechanical or prosthetic materials are implanted during surgery. Therefore, SSIs can occur in a late phase and post-discharge. So, performing a post-discharge surveillance can help the timely detection of SSIs and can prevent missing cases and under-estimation in registries systems.
As it was mentioned, In Iran, there are two independent registries in each hospital. One of them is HIM that generally recognizes and registers all disease cases using ICD-10 and ICD-9 criteria from medical reports of each patient. The other is NNIS that registers NIs in each hospital. After collecting all reported NIs from hospitals in the country, based on the NNIS report, all of them are reported to Iranian Center for Communicable Disease Control (ICCDC) in the Ministry of Health and Medical Education (24). Thus, the number of NIs and the incidence rate in country are based on case finding and case reporting of NNIS to upstream centers. After evaluation of the mentioned registry performance among six educational hospitals from March, 2017 to March, 2018, it was found that among 402 SSIs, just 241 records were reported from NNIS with 59.96% of total coverage (ranges from 50 to 90%). About 161 orthopedic SSIs that were registered based on medical reports of patients were missed by NNIS. As a result, it can be said that the performance of NNIS among the mentioned hospitals was weak and about half of cases were not detected by NNIS. So, reported incidence rates are underestimated. According to a study done by Seifi, et al, which was conducted in a hospital in Iran, sensitivity, specificity, and positive and negative predictive values of routine surveillance were 27.5%, 97.2%, 69%, and 85.3%, respectively (25). Thus, we can say the performance of the routine surveillance system is poor. To have an effective case finding and increasing the data coverage, some changes are required to be made to the infrastructure and case finding protocols.
Furthermore, after capture-recapture was observed, the completeness of NNIS was 38.68%. In other words, under-reporting of orthopedic SSIs among six educational hospitals was about 63.32%. This finding was in line with another study in which under-reporting of SSIs in ICU was 82.2% in 2019 (25). Under-reporting of SSIs in registry system is unavoidable; however, this issue can be overcome by recognizing the existing problems in the system. The possible problems in the NNIS system causing under-reporting are as follows:
Lack of data linkage between emergency units of hospitals and private clinics with NNIS:
In Iran, only in-patients with severe nosocomial infection, are registered as infected cases. Therefore, probable NIs that are referred to private clinics or hospital emergency rooms are not being recorded as nosocomial infections and it leads to possibly of missing patients with subclinical infections;
Lack of data linkage between HIM unit and NNIS;
Lack of active surveillance system: NNIS in Iran is currently a passive surveillance, it means that health care workers report notifiable nosocomial cases on a case-by-case basis and it is impossible to ensure compliance by health care providers. so, it leads to under-reporting; (26, 27)
Lack of post-discharge surveillance;
Non-reliable laboratory investigation methods (false-negative results): prescription of antibiotics, as a routine implementation before surgeries, can affect the results of laboratory tests (28) and can lead to false-negative and under-reporting;
Limited human and technical resources to register and quality control of NNIS.
With regard to the existing problems, it is recommended to plan for updating the existing prevention and controlling NNIS protocols in Iran. Some actions that can be taken are antibiotic prescription monitoring, assigning and retraining health care workers with experience of registry management and infection prevention and control, planning to provide the infrastructure for linkage of data among hospitals, clinics, and emergency units using electronic medical records, taking advantage of standardized infection ratio (SIR) as a summary measure recommended by the National Healthcare Safety Network (NHSN) to track Healthcare Associated Infections (HAI) (29), assigning a post-discharge surveillance according to the CDC ‘s recommendation based on monitoring the patients within 30 days of a surgical procedure or up to 90 days for implanted prosthetics (30). Although this issue is difficult and challenging to implement, using active surveillance can be implemented and accessible. For example, using telephone interview as a diagnostic tool for post-discharge surveillance and follow-up of patients, have shown good results in terms of reliability and validity (72% sensitivity and 100% specificity), (31) using questionnaires reported by physicians or surgeons and health care workers in local health centers (32), and providing advice to patients at the time of discharge to return for post-operative visits (33) can help to prevent and decrease the missed NIs.
Some limitations of the current study should be noted. First, because of the lack of time and the large number of hospitals, we could not conduct a study on all educational hospitals in Tehran province. Second, since private hospitals did not cooperate, we conducted this study in six educational hospitals in Tehran.