• The GlobalSurg Collaborative have been professionally crowd-sourcing wordwide surgical outcomes data since 2014.

• Local hospital data is collected and entered into our secure database by research-minded individuals from medical students to clinical professors.

• GlobalSurg 1 (July to Dec 2014) collected worldwide mortality data following emergency abdominal surgery. This included anonymised data for 10 745 patients from 357 hospitals in 58 countries.

• GlobalSurg 2 (Jan 2016 to July 2016) collected surgical site infections data following gastrointestinal surgery. This included anonymised data for 12 539 patients from 343 hospitals in 66 countries.

• The full dataset of GlobalSurg 2 can be accessed interactively at ssi.globalsurg.org.

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

globalsurg.org

What is surgical site infection?

Surgical site infection (SSI) is when the wound from surgery becomes infected. It is the most common complication following operations and causes significant pain and a prolonged recovery time for patients.

Why is surgical site infection important?

SSI is costly for patients in terms of their health, but also places a significant financial burden on healthcare systems - it has been estimated to cost $35 000 for a hospital admission for SSI in the US. Patients in low and middle income countries (LMIC) can be more profoundly affected, particulary when treatment is self-funded.

What do we know about SSI in low-income countries?

Most data relating to SSI has been collected in high income countries and standardised, internationally comparable data on SSI in low income countries is lacking. This knowledge gap makes strategic planning and allocation of resources to tackle SSI in LMIC challenging.

What is the GlobalSurg collaborative?

The GlobalSurg Collaborative takes an innovative approach to healthcare data collection and has formed an international network of surgical researchers. Recruited by social media, the ethos of GlobalSurg is inclusive and collaborative - any healthcare facility anywhere in the world treating patients that meet the inclusion criteria of the study is eligible to take part. This network acts to 'professionally crowd source' data

What was the primary aim of the GlobalSurg 2 study into SSI?

This study aimed to determine the variability of SSI rates in high, middle and low income countries.

When and where was it done?

Between January and July 2016, researchers around the world entered data on 12,539 patients undergoing abdominal surgery from 343 hospitals in 66 countries. 58.5% of patients were from high income countries (193 hospitals in 30 countries), 31.2% from middle income countries (82 hospitals in 18 countries) and 10.2% from low income countries (68 hospitals in 18 countries).

What did the study find?

The study found the number of patients suffering an SSI within 30 days of their operation, increased from 9.4% in high income countries, to 14.0% in middle income countries, and 23.2% in low income countries. Even after adjusting for confounding factors, the study demonstrated that patients in low income countries are 60% more likely to suffer a surgical site infection after an operation than those in high or middle income countries. Those who developed an SSI were more likely to die, to require a second operation, to develop a further infection, and spent at least three times as long in hospital compared to those without an SSI.

Were there differences in the use of antibiotics?

These findings were despite the greater consumption of antibiotics both before and after operations in low income countries, with 50% of patients receiving antibiotics for 5 or more days after their operation, compared with 25% of patients doing so in high income countries.

I've heard antibiotics are not as effective now. Were infections caused by drug-resistant bugs?

Testing the bacteria responsible for the surgical site infection was possible in 610 patients with an SSI. 21.6% of these patients were found to have a bacterial infection that was resistant to the prophylactic antibiotic administered before their operation. Furthermore, the rate of antibiotic resistant bacteria was higher in low income countries compared to high income countries. We cannot be conclusive about antibiotic resistance from this study, but it suggests resistance is higher in low income countries, which is of great concern.

What will you do next?

Overall, this study provides high quality evidence that patients in low income countries carry a significant burden of global surgical site infections. Such high quality evidence provides the rationale to plan, fund and perform high quality surgical research such as multi-centre, multi-country randomised controlled trials that can effect change in healthcare policy.

Full article available at http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(18)30101-4/fulltext

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

globalsurg.org

Background Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world.

Methods This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were strati ed into high-income, middle-income, and low-income groups according to the UN’s Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to a ect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (de ned by US Centers for Disease Control and Prevention criteria for super cial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231.

Findings Between Jan 4, 2016, and July 31, 2016, 13265 records were submitted for analysis. 12539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p<0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low- HDI countries (p<0·001).

Interpretation Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication.

Funding DFID-MRC-Wellcome Trust Joint Global Health Trial Development Grant, National Institute of Health Research Global Health Research Unit Grant.