Prevalence and Risk Factors of Surgical Site Infections Associated with War-Related Penetrating Abdominal Trauma in Yemen

doi:10.21203/rs.3.rs-4889145/v1

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Prevalence and Risk Factors of Surgical Site Infections Associated with War-Related Penetrating Abdominal Trauma in Yemen

https://doi.org/10.21203/rs.3.rs-4889145/v1

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Purpose

This study aimed to investigate the prevalence, risk factors, and outcomes of surgical site infections (SSIs) in patients with war-related penetrating abdominal trauma in Yemen.

Patients and methods:

A prospective cohort study was conducted involving 120 male patients (mean age, 25.52 years) who presented with penetrating abdominal trauma and underwent laparotomy. Data on demographic characteristics, injury mechanisms, clinical presentations, intraoperative findings, and postoperative outcomes were collected and analyzed.

Results

The prevalence of SSIs was 56.67%. Organ/space SSIs were the most common type (21.67%), followed by superficial incisional SSI (18.33%) and deep incisional SSI (16.67%). Significant risk factors for SSIs included hollow viscus injuries (p = 0.003), small bowel injuries (p = 0.038), higher median PRBC units received within 24 hours (p = 0.000), lower serum albumin levels (p = 0.003), and a higher number of exploratory laparotomies (p = 0.000). The median time from injury to surgery was longer in patients with SSIs (p = 0.006). However, logistic regression showed patients who received more PRBC units were less likely to develop SSIs (OR : 0.490, CI: 0.297–0.808 ,p = 0.005). Postoperative complications included anastomotic leaks (13.33%), septicemia (30%), and reoperation (20%). The mean length of ICU admission was 2.13 days, and the mean length of hospital stay was 8.56 days.

Conclusion

This study revealed a high prevalence of SSIs among patients with war-related penetrating abdominal trauma in Yemen. Key risk factors include hollow viscus and small bowel injuries and the need for extensive blood transfusions. The findings emphasize the importance of timely resuscitation and strict infection control measures to reduce SSIs and improve patient outcomes in conflict-affected regions. Enhanced medical infrastructure and effective intervention strategies can mitigate the burden of SSIs. Future research should explore the impact of blood transfusion practices and advanced infection control protocols in such settings.

General Surgery

Surgical site infections (SSIs)

war-related trauma

penetrating abdominal trauma

risk factors

blood transfusion

Yemen

This study examined how common surgical site infections (SSIs) are among patients who have suffered abdominal injuries during the war in Yemen. We looked at 120 male patients, all around 25 years old, who needed surgery for their injuries.

We found that more than half of these patients (56.67%) developed infections at the site of their surgery. The most common types of infections were deep inside the body, with some infections occurring on the surface or just under the skin.

Certain factors made infections more likely: severe internal injuries, injuries to the small intestine, and receiving more blood transfusions within the first 24 hours after injury. Lower levels of a protein called albumin in the blood and needing multiple surgeries also increased the risk.

Patients with infections faced many complications, such as leaks where organs had been sewn back together, widespread infections in the blood, and needing additional surgeries. These infections led to longer stays in intensive care and the hospital.

The study showed the importance of quickly providing enough blood to injured patients and maintaining strict infection control practices. Improving hospital resources and medical procedures could help reduce these infections and improve outcomes for patients injured in war. Future research should look at how blood transfusions and better infection control can help prevent these serious infections.

Surgical site infections (SSIs) represent a significant complication in the postoperative care of patients, contributing to increased morbidity, prolonged hospital stays, and increased healthcare costs.^1,2 The prevalence of SSIs is particularly concerning in conflict zones where healthcare infrastructure is often compromised and medical interventions are delayed because of challenging conditions.³ Yemen, a country ravaged by prolonged conflict, exemplifies such an environment that poses severe risks for patients undergoing surgery, especially those with penetrating abdominal trauma.

The incidence of SSIs in Yemen is alarmingly high. Studies in other conflict zones, such as Iraq and Afghanistan, have reported SSI rates ranging from 10–50%.^4,5 However, preliminary data suggest that prevalence in Yemen may exceed these figures significantly, likely due to factors such as limited access to healthcare facilities, scarcity of medical supplies, unsanitary conditions, and delays in receiving timely surgical care.⁶

Several studies have identified specific risk factors for SSIs, including the type and severity of the injury, nutritional status, and extent of surgical intervention required.^7,8 For instance, patients with hollow viscus injuries are at a higher risk of developing SSIs due to the increased risk of contamination.^9–11 Similarly, those with small bowel injuries are also at an elevated risk, as these injuries often result in the spillage of intestinal contents, leading to severe infections¹²

Furthermore, the role of blood transfusions in the development of SSIs has been a subject of debate. While some studies suggest that blood transfusions increase the risk of infection because of immunomodulatory effects,¹³ others argue that adequate resuscitation and stabilization through timely transfusions can improve tissue perfusion and oxygenation, potentially reducing the risk of infections.^14,15 This complex relationship underscores the need for further research to elucidate the mechanisms by which blood transfusions influence infection risk.

Considering these challenges, this study aimed to provide a comprehensive analysis of the prevalence and risk factors of SSIs among patients with war-related penetrating abdominal trauma in Yemen. By examining the specific conditions and interventions that contribute to the high rates of SSIs, we seek to inform better clinical practices and policies that can mitigate these risks and improve patient outcomes in conflict-affected regions.

Study Design and Setting

This prospective cohort study investigated the incidence, risk factors, and outcomes of surgical site infections (SSIs) in patients with war-related penetrating abdominal trauma. The study was conducted at the General Military Hospital, a major trauma center in a conflict region, from January to December 2022.

Participants

Eligibility Criteria

Adults aged 18 years and older with penetrating abdominal trauma from war-related activities were included. Injuries from high-velocity projectiles, blasts, or other warfare mechanisms requiring exploratory laparotomy or damage control surgery are eligible for inclusion. The exclusion criteria were isolated blunt abdominal trauma, patients who did not survive initial resuscitation, those who were referred or discharged before 72 hours, and those with incomplete medical records.

Recruitment

Patients were consecutively recruited upon admission to the trauma center. Informed consent was obtained from all participants or their legal guardians.

Data Collection

Baseline Data

Upon admission, demographic and clinical data, including age, body mass index, mechanism of injury, Injury Severity Score (ISS), and associated injuries, were collected through interviews, medical records, and physical examination.

Intraoperative Data

Details such as surgical approach, time from injury to surgery, intraoperative findings, and specific organ injuries were documented. The number of packed erythrocytes (PRBCs) transfused within 24 h of admission was recorded.

Postoperative Data

Patients were followed up for 30 days after surgery to monitor SSIs using the CDC criteria. Additional postoperative complications, ICU length of stay, and total hospital stay were also recorded.

Variables

Primary Outcome

The primary outcome was the incidence of SSIs, defined as infections occurring at or near the surgical incision within 30 days of the procedure or within 1 year if an implant was left in place. SSIs were classified as superficial incisional, deep incisional, and organ/space SSIs.

Secondary Outcomes

Secondary outcomes included length of ICU admission, length of hospital stay, and incidence of various postoperative complications.

Exposure Variables

Key exposure variables included demographic factors (age, sex, BMI), clinical factors (mechanism of injury, ISS, associated injuries), intraoperative factors (surgical approach, operative duration, time from injury to operation), and postoperative management (use of prophylactic antibiotics, need for reoperation).

Bias

Efforts were made to minimize selection bias by consecutively recruiting eligible patients upon admission. Information bias was minimized using standardized data collection forms and trained personnel to collect data. Confounding factors were addressed by including key variables in the multivariate analysis.

Statistical Methods

Descriptive statistics summarized patient characteristics, intraoperative details, and postoperative outcomes. Continuous variables are presented as means (SD) and categorical variables as frequencies and percentages. The incidence of SSIs was calculated, and potential risk factors were analyzed using chi-square tests for categorical variables and t-tests for continuous variables. Logistic regression identified independent predictors of SSIs. A p-value of < 0.05 was considered statistically significant. Analyses were conducted using SPSS software (version 26.0)..

Ethical Considerations

The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the Institutional Review Board of the General Military Hospital (Approval Reference Number: GMH-IRB-2024-001). Informed consent was obtained from all patients or their legal guardians prior to their inclusion in the study. The confidentiality and anonymity of patient data were strictly maintained throughout the study.

Demographic and Clinical Characteristics of Patients

The demographic and clinical characteristics of the study population are summarized in Table 1. The majority of the patients were young males (mean age 25.52 years) with a mean BMI of 22.36 Kg/m². The most common mechanisms of injury were gunshot wounds (57.5%) and non-IED blast injuries (41.67%). The Injury Severity Score (ISS) indicated that a significant proportion of patients sustained moderate to severe injuries.

Table 1. Demographic and Clinical Characteristics of the Study Population

Variable	Category	Frequency	Percentage
Age (years)	Mean ± SD	25.52 ± 4.42
BMI (Kg/m²)	Mean ± SD	22.36 ± 17.89
Injury Severity Score	Mean ± SD	14.60 ± 5.22
Sex
Male	Yes	120	100.00%
Injury Mechanism
GSW	Yes	69	57.50%
Non-IED Blast (shrapnel)	Yes	50	41.67%
IED Blast	Yes	1	0.83%
Injury Severity Class
Moderate (10-15)	Yes	57	47.5
Severe (16-25)	Yes	43	35.83
Minor (0-9)	Yes	18	15
Critical (≥26)	Yes	2	1.67
PRBC units within 24 hrs post-injury	Mean ± SD	1.79 ± 1.31
Associated body injury
Yes		59	49.17
Other associated injury
Extremity wounds or pelvic girdle	Yes	42	35
Chest wounds	Yes	24	20
Head/Neck wounds	Yes	1	0.83

Abbreviations: SD, Standard Deviation; BMI, Body Mass Index; GSW, Gunshot Wound; IED, Improvised Explosive Device; PRBC, Packed Red Blood Cells.

Intraoperative Findings

Intraoperative findings revealed a high prevalence of hollow viscus injuries (73.33%) among the patients, indicating the severity of the trauma. Colorectal injuries were present in 47.5% of patients, and solid organ injuries were observed in 27.5% of cases. A small percentage (4.17%) of patients had no significant intraoperative injuries (Table 2). These findings underscore the complex nature of the injuries sustained and the necessity for thorough surgical exploration.

Table 2. Intraoperative Findings Among the Study Population

Variable	Frequency	Percentage
Time from injury to operation (hrs) (Median (Range))	10 (5-72)
Surgical approach
Exploratory laparotomy	119	99.17%
Damage control surgery	1	0.83%
Indications for surgery
CT findings of intra-abdominal injury	114	95%
Positive FAST exam	113	94.17%
Hemodynamic instability	8	6.67%
Peritonitis on physical examination	4	3.33%
Injury Findings
Hollow Viscus Injury	88	73.33%
Colorectal Injury	57	47.5%
Solid Organ Injury	33	27.5%
Negative finding	5	4.17%
Specific Organ Injuries
Small Bowel Injury	66	55%
Colon Injury	60	50%
Gastric Injury	14	11.67%
Rectum Injury	10	8.33%
Diaphragm Injury	9	7.5%
Spleen Injury	6	5%
Kidney Injury	6	5%
Liver Injury	5	4.17%
Bladder Injury	4	3.33%
Retroperitoneal Hematoma Injury	3	2.5%
Pancreas Injury	2	1.67%
Biliary Tree Injury	2	1.67%
Abdominal Vascular Injury	2	1.67%
Surgical Procedures
Primary repair of small bowel	64	53.33%
Primary repair of colon injury with proximal colostomy	25	20.83%
Primary repair of colon injury	20	16.67%
Resection and anastomosis of bowel injury with proximal ileostomy	14	11.67%
Primary repair of stomach	14	11.67%
Rectal injury repair with diverting loop colostomy	10	8.33%
Repair of diaphragmatic tear	9	7.5%
Resection of small bowel with primary anastomosis	7	5.83%
Hepatorraphy	5	4.17%
Renorraphy	5	4.17%
Splenectomy	4	3.33%
Repair of urinary bladder rupture	4	3.33%
Resection and anastomosis of colon	3	2.5%
Distal pancreatectomy	2	1.67%
Spelenorraphy	2	1.67%
Nephrectomy	1	0.83%
Stoma creation	49	40.83%
Operative duration (min) Mean ± SD	170.76 ± 46.19

Abbreviations: hrs, hours; CT, Computed Tomography; FAST, Focused Assessment with Sonography for Trauma; SD, Standard Deviation; min, minutes.

Postoperative Complications

Table 3 outlines the postoperative complications observed in the study population. Notably, over half of the patients (56.67%) developed surgical site infections (SSIs). Other significant complications included anastomotic leaks (13.33%), wound dehiscence (12.5%), and septicemia (30%). These complications contributed to longer ICU admissions and hospital stays, highlighting the severe impact of SSIs on patient outcomes.

Table 3. Postoperative Complications Among the Study Population

Variable	Frequency	Percentage
Postoperative complications	68	56.67%
Surgical site infection (SSI)	68	56.67%
Anastomotic leak	16	13.33%
Bile leak	2	1.67%
Wound dehiscence / Burst abdomen	15	12.5%
Enterocutaneous fistula	18	15%
Pancreatic fistula	2	1.67%
Paralytic ileus	20	16.67%
Septicemia	36	30%
Reoperation	24	20%
Length of ICU admission (days)	Mean ± SD	2.13 ± 1.11
Length of hospital stay (days)	Mean ± SD	8.56 ± 3.49

Abbreviations: SSI, Surgical Site Infection; ICU, Intensive Care Unit; SD, Standard Deviation.

Incidence and Management of SSIs

The incidence of SSIs was significant, with 56.67% of patients developing infections. Organ/space SSIs were the most common type, followed by superficial and deep incisional SSIs (Table 4). Management strategies varied, with conservative treatment being the most common approach.

Table 4. Incidence of SSIs and Management Strategies

Variable	Frequency	Percentage
Average days to develop SSI postop (Mean ± SD)	3.79 ± 0.61
Type of SSI
Organ/space SSI	26	21.67%
Superficial incisional SSI	22	18.33%
Deep incisional SSI	20	16.67%
Management received for SSI
Conservative (Dressing and Antibiotic)	39	32.5%
Relaparotomy	24	20%
Debridement	9	7.5%
Suturing	6	5%
Percutaneous drainage	2	1.67%

Abbreviations: SSI, Surgical Site Infection; postop, postoperative; SD, Standard Deviation.

Risk Factors for SSIs

Table 5 presents the relationship between various variables and the development of SSIs. Significant risk factors included hollow viscus injuries, small bowel injuries, and the number of PRBC units received within 24 hours post-injury.

Table 5: Risk Factors Associated with the Development of Surgical Site Infections (SSIs)

Variable	SSI (Yes)	SSI (No)	Total (n=120)	p-value
Hollow Viscus Injury	57 (84%)	31 (60%)	88 (73%)	0.003*
Negative Finding (No Injuries)	0	5 (10%)	5 (4%)	0.014**
Small Bowel Injury	43 (63%)	23 (44%)	66 (55%)	0.038*
Number of PRBC Units within 24hrs (median, range)	2 (0-5)	1 (0-3)	-	<0.001***
Serum Albumin Levels (median, range)	3.15 (1.4-4.4)	3.6 (1.7-4.2)	-	0.003***
Total Number of Exploratory Laparotomies (median, range)	1 (1-3)	1 (1)	-	<0.001***
Time from Injury to Operation (hrs) (median, range)	10 (5-72)	9 (6-14)	-	0.006***

Notes: * Significant p-value using chi-square test. ** Significant p-value using Fisher's exact test. *** Significant correlation using Mann-Whitney test.

Abbreviations: SSI, Surgical Site Infection; PRBC, Packed Red Blood Cells; hrs, hours.

Logistic regression analysis identified the number of PRBC units received within 24 hours post-injury as a significant independent risk factor for SSIs. This variable showed an inverse relationship to the likelihood of developing SSIs (OR: 0.490, CI: 0.297-0.808, p = 0.005). This suggests that patients receiving more PRBC units were less likely to develop SSIs, likely due to improved tissue perfusion and oxygenation aiding wound healing.

Our study revealed a significant prevalence of surgical site infections (SSIs) among patients with war-related penetrating abdominal trauma in Yemen, with an overall rate of 56.67%. This rate is significantly higher than those in other conflict zones like Iraq and Afghanistan, where rates range from 10% to 50%.^16,17 The high prevalence of HIV in Yemen can be attributed to challenging conditions, such as limited healthcare infrastructure, delayed medical interventions, and unsanitary environments.

Significant risk factors for SSIs were identified. Patients with hollow viscus injuries had an 84% likelihood of developing SSIs, compared with 60% for those without such injuries. This finding is consistent with existing literature, which highlighted the increased risk of infection due to the higher likelihood of contamination in hollow viscus injuries.^17–19 Similarly, patients with small bowel injuries had a 63% incidence of SSIs compared with 44% in those without such injuries, which is consistent with previous studies indicating a high probability of major infection following traumatic intestinal perforation.^20,21 The study found that receiving higher median units of packed red blood cells (PRBC) within 24 hours post-injury was associated with a greater likelihood of developing SSIs (2 units versus 1 unit). This suggests that extensive blood transfusion might indicate more severe trauma, leading to an increased risk of infection.^17,20,22,23 Lower median serum albumin levels were linked to a higher incidence of SSIs (3.15 mg/dL versus 3.6 mg/dL), consistent with the understanding that hypoalbuminemia is a well-known risk factor for poor wound healing and increased susceptibility to infections.²⁴ Additionally, patients with SSIs underwent more exploratory laparotomies, with a median range of 1-3 compared to a median of 1 in those without SSIs. Multiple surgeries can increase the risk of infection due to repeated exposure and potential contamination. The median time from injury to surgery was slightly higher in patients with SSIs (10 hours versus 9 hours), indicating that delays in surgical intervention can contribute to the development of infections due to prolonged exposure to contaminants.²⁵

SSIs are associated with various postoperative complications. These included anastomotic leaks (13.33%), bile leaks (1.67%), wound dehiscence (12.5%), enterocutaneous fistula (15%), pancreatic fistula (1.67%), paralytic ileus (16.67%), septicemia (30%), and reoperation (20%). These complications align with existing literature that highlights the severe impact of SSIs on patient outcomes, including increased morbidity and mortality.¹⁸ Patients with SSIs had longer intensive care unit admissions (mean of 2.13 days) and hospital stays (mean of 8.56 days). This finding is consistent with that of previous studies reporting that SSIs prolong hospitalization and increase healthcare costs.^22,26 The primary management strategies for SSIs in our cohort included conservative treatment with dressing and antibiotics (32.5%), relaparotomy (20%), debridement (7.5%), suturing (5%), and percutaneous drainage (1.67%). These management approaches reflect standard practices for treating SSIs although the high reliance on conservative treatment may be attributed to limited surgical resources in Yemen.²⁷

Logistic regression analysis identified the number of PRBC units received within 24 hours post-injury as a significant independent risk factor for SSIs. Interestingly, patients receiving more PRBC units were less likely to develop SSIs, suggesting that adequate blood transfusion might play a protective role in reducing the risk of infection. This finding supports the importance of adequate resuscitation and stabilization for trauma care. Proper resuscitation improves tissue perfusion and oxygenation, potentially reducing the risk of infections, including SSIs. This finding contrasts with some studies suggesting that blood transfusions can increase infection risk because of immunomodulatory effects, underscoring the complexity of this relationship.^17,20–23 Our findings are consistent with other studies that have identified similar risk factors and complications associated with SSIs in war-related trauma. For instance, the high prevalence of SSIs in our study mirrors findings in other conflict zones, where harsh conditions and limited medical resources contribute to elevated infection rates.^18,25 Moreover, the identification of specific risk factors, such as hollow viscus and small bowel injuries, as well as the importance of timely surgical intervention aligns with the existing literature on trauma surgery.¹⁸

Despite the strengths of our study, including its prospective design and comprehensive data collection, several limitations should be noted. First, the study was conducted at a single trauma center, which may limit the generalizability of our findings to other settings. Second, the lack of standardized protocols for managing penetrating abdominal trauma in Yemen may have introduced variability in patient care and outcomes.

The findings underscore the importance of early and adequate blood transfusion for patients with penetrating abdominal trauma. The association between higher PRBC units and reduced SSIs suggests that timely and sufficient resuscitation is critical for preventing infections. Additionally, the significant risk of hollow viscus and small bowel injuries highlights the need for stringent infection control measures in these patients. Future research should explore the mechanisms by which blood transfusions influence infection risk, considering both the immunomodulatory effects and the benefits of adequate resuscitation. Larger, multicenter studies are needed to confirm these findings and provide more generalizable data. Investigating the role of advanced infection control protocols and their impact on SSIs in patients with specific intra-abdominal injuries could improve patient outcomes.

This study revealed a high prevalence of SSIs among patients with war-related penetrating abdominal trauma in Yemen. Significant risk factors include hollow viscus, small bowel, and inadequate blood transfusions. These findings emphasize the importance of timely resuscitation, stringent infection control measures, and comprehensive nutritional support to improve patient outcomes in conflict-affected regions. Enhanced medical infrastructure and effective intervention strategies are essential to mitigate the mortality of SSIs. Future research should focus on the impact of blood transfusion practices and advanced infection control protocols to reduce SSIs in high-risk populations.

Acknowledgments

Not applicable.

Ethical Approval

This study was approved by the ethics committee of the General Military Hospital. This study was conducted in accordance with the ethical guidelines of the Declaration of Helsinki. Written informed consent was obtained from all patients.

Disclosure

The authors declare no conflicts of interest.

Competing of interest

Nonfinancial competing interests

Funding disclosure

This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability

The datasets used and/or analyzed in this study are available from the corresponding author upon reasonable request.

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Prevalence and Risk Factors of Surgical Site Infections Associated with War-Related Penetrating Abdominal Trauma in Yemen

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Abstract

Plain Language Summary

Introduction

Materials and methods

Study Design and Setting

Participants

Data Collection

Variables

Bias

Statistical Methods

Ethical Considerations

Results

Demographic and Clinical Characteristics of Patients

Intraoperative Findings

Postoperative Complications

Incidence and Management of SSIs

Risk Factors for SSIs

Discussion

Conclusion

Declarations

References

Additional Declarations

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