Surgical site infection prevalence and associated factors in Hawassa University comprehensive specialized hospital, southern Ethiopia.

Background Surgical site infections (SSIs) continue the main problem in health care facilities, causing the prolonged length of stay, considerable morbidity, mortality, and the extra cost to patients after surgery. The aim of this study was to determine the prevalence of SSIs and explore its associated factors among surgical patients at Hawassa Methods A hospital-based cross-sectional study design was conducted among postoperative patients on a sample of 281 who were admitted and have had surgery from 1 March – 1 April 2019. Purposive sampling technique and the structured questioner were selected to gather data from the patient's medical record, interview, and observation. EPI Info 3.5.4 was a data entry software and SPSS version 20.0 was selected for analysis. Associations among variables were assessed by binary logistic regression. Result A total of 281 patients have participated and the mean age was 30.3 (±18.9) years. The prevalence of SSIs was (24.6%) (95% CI 19.6 – 29.69). Age less than 15 years AOR = 0.131 (95% CI 0.020, 0.087), having clean surgical wound AOR = 0.006 (95% CI 0.002, 0.024) were significant protective associated factors to SSIs while having open surgical wound AOR =5.189 (95% CI 1.511, 17.821) and malnutrition AOR =29.351 (95% CI 5.711, 150.851) were significant risk associated factors to SSIs. Conclusion The of SSIs bigger than the between and This needs exceptional attention to reduce the odds of surgical site infection by standardizing patient care and controlling of comorbidities.

reported. The incidence of SSI could be nearly 4 times higher in low and middle-income countries (LMIC) than in high-income countries (3).
Although SSIs are preventable complications following surgery, they are associated with longer hospitalization; pain; discomfort; delayed wound healing; prolonged or permanent disability; and, in worst cases, death (9). Additionally, SSI places a significant economic burden on health system and patient finances and resources because of lengthier hospitalizations and increased cost of treatment (10).
Surgical procedures are associated with high infection rates and mortality in developing countries because necessary resources are inadequate (20), (13).
According to the World health organization (WHO) and other studies, episodic investigation on SSIs prevalence and its related issues can reduce SSIs by up to 50% (21), (22).
There are inadequate studies concerning the prevalence of SSIs and its linked factors in Ethiopia particularly in Hawassa. Hence, this study required to determine the prevalence of SSI and explore its associated factors at Hawassa University comprehensive specialized hospital in southern Ethiopia.
The result of this study will provide baseline information to develop evidence-based strategies to diminish preventable SSIs and their adverse effects by the Federal Ministry of the health of Ethiopia and concerned non-governmental organizations.

Study design and setting
A hospital-based cross-sectional study was done from 1 March -1 April 2019. Hawassa is situated at the eastern shore of Lake Hawassa and is located 275 km to the south of Addis Ababa, the capital city of the country. Hawassa University comprehensive specialized hospital is located in the south part of Hawassa town in the SNNPR regional state. The University Hospital is the only biggest comprehensive specialized referral and teaching hospital in the region. It is giving inpatient and as an outpatient service for more than 25 million people from the surrounding zones and nearby regions. This teaching hospital consists of an operating room, intensive care unit (ICU), 16 wards with 400 beds, and 11 outpatient departments. The study was carried out at surgical ward.
Sample size and sampling procedure The sample size was determined by using a single population proportion formula with a 95% confidence interval, a 5% margin of error and adding 5% contingency for illegible handwriting and incomplete medical records.
By using the proportion of prevalence of Surgical site infection 35 % as published data was acquired from the Addis Ababa study (23) the sample size was calculated as follows.
=350 Therefore, by adding 10 % for possible non-response rate, the final sample size was =385.
Then since the study population is < 10,000 correction formula was used as follows:

Data collection tools and procedures
A structured data collection tool was used to capture data from medical records, patient charts and study participants who developed surgical site infections.
The selected patients were assessed by physical examination using the observational checklist adopted from the US Center for Disease Control and Prevention (CDC) criteria (24). The data collectors were trained for one day on data collection methodology and related issues prior to the start of data collection and were closely supervised by 2 MSc nurses during the data collection. Filled checklists were checked on a daily bases for completeness, clarity, and accuracy. Data cleaning was undertaken before entry and analysis.

Statistical analysis
Data entry was done by using EPI Info 3.5.1 and exported to SPSS version 20.0 software package for analysis. The descriptive analysis including frequency and cross tabs were used to assess the frequency of variables with independent variables. Binary logistic regression was carried out to assess the association of dependent variable with independent variables and to determine predictors of SSI using odds ratios with 95% confidence interval (CIs).
Finally, forward stepwise logistic regression model with all independent variables having p-value <0.25 were fitted and adjusted odds ratio (AORs) were calculated to identify independent predictors of SSI among patients undergone surgery. A value of p< 0.05 was considered statistically significant.

Results
Socio-demographic characteristics of the study participants A total of 281 patients have participated and the age ranged from 1 to 80 years with the mean age of 30.3 (±18.9) years. Female accounts (54.1%) and more than half of them were from rural in residency (51.6%). Concerning the educational status of the participants, the majority (38.1%) accomplished grades 1-8. (Table1). The Surgical condition and clinical characteristics of patients   Figure 1).   (Table 3). Malnutrition is a well-documented risk factor for SSI (27), (28), (33).

Limitation of the study
Since the study design was cross-sectional, it is difficult to establish a sequential relationship between surgical site infections and descriptive variables. Further, a short study period limited us to take large sample size. Also due to resource shortage, variables related to health professional's infection prevention practice, equipment sterilization methods and types of antiseptics used for patient preparation were not studied.

Conclusions
The prevalence of SSIs was bigger than the worldwide range (1.2%) to (5.2%), even higher compared to reports from many developing countries and it is a significant problem in the study hospital.  A v a i l a b i l i t y o f d a t a a n d m a t e r i a l s All data generated or analyzed during this study are included in this published. We sent all data which are available; there is no remaining data and materials. There is no any fund for publication. The study design and manuscript was designed and written by authors.
A c k n o w l e d g m e n t We are very grateful to the college of medicine and health sciences of Hawassa University for technical and financial support. The authors also acknowledge data collectors who showed the greatest effort in acquiring appropriate information. The hospital also deserves thanks for the assistance and permission to undertake the research.