Infections caused by an invasive surgical procedure that occurs in the wound are generally appertained to as surgical point infections (SSIs) [1]. It's clinically characterized as an infection that occurs within 30 days of surgery (or within a time if an implant is left in place after the procedure) and affects either the gash or deep towel at the point of the surgery [2]. These infections can be superficial or deep incisional infections, or infections affecting organs or body spaces. SSIs are the most common infections associated with health care settings. They're associated with significant morbidity, and over one- third of postoperative deaths have been reported to be linked to SSI [3, 4]. SSI will double the duration of a case's hospital stay and thus increase the cost of health care [4]. Depending on the type of surgery and the inflexibility of the infection, redundant costs due to SSI of between 8,000 and 27,000 INR have been recorded.

Impurity of the wound point and pathogenicity of microorganisms, balanced against the host's vulnerable response, will determine the circumstance of SSI [7 – 9]. The organism that causes SSI are generally deduced from the endogenous terrain, that is, the case's skin or opened viscus. Surgical instruments or theatre surroundings can pollute the point during operation, leading to exogenous causes of SSI [2, 10, 11]. Hematogenous spread of organisms from distant sources of infection can infrequently beget SSI by attachment to the prosthesis or other implant left in the operative point. The infection forestallment and control practices of SSI are thus aimed at minimizing the number of pathogens at the surgical point [12, 13]. The most common microorganism dressed from SSIs is Staphylococcus aureus [14 – 16]. When a viscus, similar as the large bowel, is opened, skins are likely to be defiled by multitudinous organisms. For illustration, Enterobacteriaceae and anaerobes can beget SSI after colorectal surgery [11]. The presence of a foreign body from prosthetic surgery reduces the number of pathogenic organisms needed to beget SSI [17, 18]. Microorganisms, which are non-pathogenic, similar as Staphylococcus epidermidis, may also beget SSI in such an terrain.

The type of wound also dictates the presence of microorganisms at surgical spots. For case, operations on sterile spots have lower than 2%, whereas SSI will do in further than 10% after operations in" contaminated" or" dirty" spots [19, 20]. Resistance patterns of SSI associated bacteria vary encyclopedically, depending on the region, original epidemiology reports, and vulnerability testing methodology. Bacterial resistance poses a challenge and complicates the SSI treatment. Utmost of the data on medicine resistance were attained from high- income countries [21, 22]. Still, there were limited reports on the frequency and prevalence of resistant bacteria causing SSI, especially from developing countries [21, 23]. Thus, this study aimed to assess the bacterial profile and antimicrobial vulnerability patterns of isolates among cases diagnosed with surgical point infectio n in the Department of Surgery of a tertiary care hospital in Northeast India.

Study area and period

The study was conducted at a teaching tertiary care hospital of Northeast India, which has around 500 beds with 22 departments. The surgery department has about 90 beds. The study was conducted from April 2023 to September 2024.

Study design and population

A hospital based study was employed among adult cases (age ≥ 18 times) who passed either optional or exigency surgical procedures in the Department of General Surgery. All the eligible cases were followed for 30 days for the circumstance of SSI. From those who developed SSI during the 30 days of follow up, pus sample was collected for bacteriological analysis. We barred cases who were originally diagnosed with SSIs, failed within 48 h, or refused to share in the study.

Data collection procedures and wound swab sample collection

For sociodemographic and clinical characteristics of the cases, a predesigned and semi-structured questionnaire was used. The current study used the Centers for Disease Control and Prevention (CDC) SSI surveillance styles [25]. Trained study sidekicks (one nanny and one clinical druggist in the profession) conducted circular surveillance by acquiring patient information using a form containing SSI threat factors. The clinical evaluation of surgical sites (wound) was done by the attending doctor. The clinical features of the wound, similar as pain, greenishness, swelling, warm skin around the wound, green discharge, unwelcome odor, fever, and chills, were considered for the clinical opinion of surgical point infection. The wound bed with suspected bacterial infection was prepared for sample collection with sterile cotton swab diupped in sterile normal saline. All surgical spots were audited 24 – 48 h after surgery at the time of change of dressing. Pus samples from injuries were aseptically collected using sterile cotton. For post-discharge surveillance, cases were asked to return for follow- up within 30 days post-discharge at the hospital's surgical inpatient clinic.

Culture of specimen

The clinical samples (i.e., pus, pus aspirates, and wound swabs) were collected aseptically and reused incontinently in the microbiology laboratory within 30 min by placing the hearties into sterile test tubes containing 0.5 ml of sterile normal saline. The collected samples were invested onto MacConkey's agar, Blood agar, and chocolate agar plates. also, the invested MacConkey's and Blood agar plates were incubated in aerobic conditions, while Chocolate agar plates were incubated in a 5 – 10% CO2 atmosphere at 37 °C for 24 – 48 h..

Identification of bacterial pathogens

Characterization of cultures was done using morphological appearances on selective and differential media. Grounded on standard methods [26], the motility tests and biochemical tests were carried out.

Antibiotic susceptibility test

From each confirmed culture isolate, a suspension of a pure colony was made in sterile normal saline, which was incubated at 37 °C for at least 15 min. For uniformity of a suspension on Mueller–Hinton agar (Oxoid Ltd), a sterile cotton-tip applicator stick was used. For the antibiotic susceptibility test (AST), the Kirby-Bauer disk diffusion technique was implemented. For the AST, different antibiotic disks were used. These were Ciprofloxacin (5 μg), Penicillin (10 IU), Clindamycin (2 μg), Gentamycin (10 μg), Trimethoprim-Sulfamethoxazole (1.25/23.75 μg), Erythromycin (15 μg), Tetracycline (30 μg), Ceftriaxone (30 μg), Ampicillin (10 μg), Chloramphenicol (30 μg), Meropenem (10 μg), Ceftazidime (30 μg), Vancomycin (30 μg), Cefepime(30 μg) and, Cefuroxime(30 μg) (Oxoid Ltd). The zone of inhibition was measured using a ruler. The AST result was classified as susceptible, intermediate, and resistant using the Clinical and Laboratory Standards Institute (CLSI) 2024 performance standards for antimicrobial susceptibility testing interpretation [27].

Data and laboratory quality control

Different techniques were used for data quality management. These included standardization of data collection materials, training of data collectors, and supervision during data collection. To ensure the appropriateness of the data collection tool, the questionnaire was pretested before the actual study. The quality assurance process that is incorporated in the standard operating procedures of the Bacteriology Laboratory of the Hospital was strictly followed for laboratory analysis. An experienced medical laboratory technologist participated in the laboratory identification procedure. The performance of prepared media was checked by inoculating control strains, S. aureus (ATCC-25923) and E. coli (ATCC-25922) as controls. In addition, sterility was checked by incubating 5% of prepared media at 37 °C for 24–48 h, and reagents for gram stain and biochemical tests were checked by standard strains of S. aureus and E. coli.

Data analysis

Complete data were entered in MS Excel and exported to WHONET. To present antimicrobial susceptibility patterns, descriptive statistics were used. Frequencies and cross-tabulations were used to summarize descriptive statistics. Statistical significance was considered at p values less than or equal to 0.05.

Consent consideration

Written informed consent was secured from each study participant. All participants' information was kept confidential. Patients who developed SSIs were treated according to the protocol of the hospital.

Sociodemographic and clinical data

A total of 251 patients were included in the study. Out of 251 patients, 122 (48.6%) were females. The mean ± SD age of the study participants was 38 ± 16.30 years. Nearly three-fourths of patients were from rural areas. More than two-thirds of surgical procedures were emergent. About 148 (59%) of surgical incision sites were abdominal. The clean or clean contaminated dominated the wound class, whereas only 37 (14.74%) patients had contaminated wounds. Nearly one-fourth of patients, 61 (24.3%), had an extended duration of preoperative hospital stay of ≥ 7 days.

Disease comorbidity

Fifty-nine (23.51%) of patients presented with one or more co-morbidities. The common ones were cardiac disorder  20  (7.97%),  respiratory disorder  7  (2.79%), psychiatric problem 7 (2.79%), diabetic mellitus 6 (2.39%), malignancy 6 (2.39%), and HIV/AIDS 4 (1.59%) [Table 1].

Table 1

Identified bacterial isolates

From patients who developed SSI (n = 118), wound swabs or pus aspirates were collected. Out of these, 73.7% (87/118) were culture positive, while the rest, 26.3% (31/118), were culture negative. Out of a total of 87 bacterial isolates, 71.1% were Gram-negative, 25.3% were Gram-positive, and 3.6% were a mixture of two microbial growths. Among the types of bacteria identified, Escherichia coli accounted for 30 (34.48%), followed by Staphylococcus aureus 18 (20.69%), Klebsiella pneumoniae 17 (19.54%), Proteus mirabilis 4 (4.59%), Acintobacter spp 4 (4.59%), Citrobacter spp 4 (4.59%), Pseudomonas aeruginosa 3 (3.44%), Enterecoccus faecium 2 (2.29%), Klebsiella oxytoca 2 (2.29%), Proteus vulgaris 1 (1.15%) [Fig. 1].

Fig 1

Antibiotic susceptibility pattern of SSI isolates

Antibiotic resistance profiles were reported for the organisms isolated from the surgical incision sites of infected patients. The Gram-positive pathogens showed high resistance toward penicillin (66.67%), erythromycin (66.67%), and clindamycin (66.67%). The Gram-negative pathogens showed high resistance toward Cefepime (87.88%), ceftriaxone (78.79%), Cefuroxime (63.63%), cotrimoxazole (54.55%), ciprofloxacin (60.60%), and ampicillin (60.60%). Clindamycin and erythromycin-resistant S. aureus accounted for 80% of all S. aureus isolates and showed resistance toward cotrimoxazole (60%). However, only one strain of it showed resistance to vancomycin. Two of three isolates of Streptococcus were resistant to Penicillin, erythromycin, vancomycin, and clindamycin. All strains of Pseudomonas aeruginosa (P. aeruginosa) and Proteus spp. were resistant to Ceftriaxone. Pseudomonas aeruginosa isolates were resistant to meropenem (62.5%), ceftazidime (62.5%), ciprofloxacin (50%), and gentamicin (50%). All strains of Proteus spp. Showed resistance to cefepime and cefuroxime. Similarly, all isolates of Citrobacter spp. Showed resistance to cefepime. The identified Serratia spp. were resistant to all tested antibiotics. Meropenem is 100% effective against E. coli, which was the predominant pathogen in this study. [Table 2]

Table 2

ND not done, Ds done susceptible, CONS coagulase-negative staphylococcus

Postoperative SSI remains one of the foremost noteworthy causes of dismalness among surgically treated patients. These patients bring about higher costs due to longer hospitalizations, more nursing care, extra wound care, potential clinic affirmations, and assist surgical strategies. Distinguishing proof of bacterial pathogens and the determination of a compelling anti-microbial against the organism are basic within the effective administration of bacterial contamination. Within the current think about, the in general culture inspiration rate from patients with surgical location contamination was 73.7%, which was somewhat higher than comes about already detailed from India (68%) [28], but lower than a report from Mekelle (75%) [29] and Nigeria (82%) (30]. Lower rates of positive culture were detailed from other parts of India (50%) [31], Nepal (63.3%) [16] and Bangladesh (61.8%) [32].

The confinement rate of Gram-negative bacteria was greater (71.1%) than that of Gram-positive bacteria (25.3%) in this study. This is in contrast to a study done in Bangladesh [32] and Nepal [33, 34]. This might be related to the study population. Within the last mentioned considers, most of the patients were from the orthopedics division, where Gram-positive microscopic organisms such as Staphylococcus and Streptococcus are the most causative operators [35, 36]. The predominance of blended diseases within the current consider (3.6%) was lower than that specified in different thinks about from Jimma (22.9%) [37], Dessie (18.5%) [38] and Nigeria [33.2%) [39].

The contrast may be due to contrasts in recognizable proof strategies, which are known to impact the relative predominance of bacteria. Similar to the display consider, S.M. Patel et al. [40] illustrated that Escherichia coli (35.7%) was the foremost common pathogenic disconnect, taken after by Staphylococcus aureus (21.4%), Pseudomonas aeruginosa (14.3%), and Klebsiella spp. (14.3%). In a comparative think about from Chennai [11], Escherichia coli (41.17%) was detailed as the foremost common bacterial disconnect, taken after by Staphylococcus aureus (13.72%), Klebsiella pneumoniae (9.80%), and Pseudomonas aeruginosa (7.84%). Varsha Shahane et al. [42] have also demonstrated Escherichia coli as the commonest isolate in their studies. A comparative consider finding from Gondar (Ethiopia) [43] detailed that Escherichia coli was a major disconnect.

Be that as it may, this finding was in contrast with numerous other studies [29, 35, 44, 49]. In these studies, Staphylococcus aureus has been documented as the commonest pathogen causing SSI. The contrast within the report may be clarified by the contrast within the setting and study populace. Within the current study, most of the patients were from the common surgery ward. Most of the surgical strategies performed were laparotomies, and most wounds were either clean-contaminated or sullied, which had spillage from the gastrointestinal tract. In this study, Proteus spp. conferred tall resistance to Cefepime (100%), Cefuroxime (100%), ceftriaxone (100%), ciprofloxacin (67%), ampicillin (67%), cotrimoxazole (67%), and chloramphenicol (67%), which concurs with reports in other studys [37, 38]. In this think about, multidrug resistance (MDR) to commonly utilized anti-microbials was distinguished. Resistance to anti-microbials extended from 11.1% to 100%. So also, a study from Mekelle (Ethiopia) [29] appeared multidrug resistance to the commonly utilized anti-microbials. In Tikur Anbessa specialized Clinic [50], almost 95% of the isolates were resistant to two or more antimicrobials, while 82.3% of them were resistant to three or more antimicrobials. Other than these comparative national considers, the current study discoveries were reliable with numerous other worldwide studies [4, 13, 29, 43, 45, 50, 51]. This may well be since these antibiotics are broadly endorsed experimentally for the treatment of different diseases in our setting. Overall, ceftriaxone resistance in this study was around 78.79%. All Pseudomonas and Proteus spp. Isolated were 100% resistant to ceftriaxone. This astoundingly higher resistance can be due to the injudicious utilization of ceftriaxone as prophylaxis to all who experienced surgery in our healing center. Indeed in spite of the fact that tall sedate resistance was watched in this study, meropenem was viable against Escherichia coli, which was the overwhelming cause of SSI within the current study. A high rate (about half) of bacterial resistance against chloramphenicol and cotrimoxazole was watched. This is ofsten steady with a study in Saudi Arabia [49]. This might be due to the injudicious utilization of anti-microbials in both hospitals. In this study, Citrobacter most extreme resistance was conferred to cefepime (100%), ampicillin (75%), ciprofloxacin (75%), ceftazidime (75%), cotrimoxazole (75%) and ceftriaxone (75%), which was comparable to the result detailed Girma et al. [37] in differentiate another study report 66.7% resistance for ampicilin [52]. The contrast may be due to the setting and the included patients in the think about. The utilization of cefepime within the study setting is exceptionally guarded.

Hence, the tall resistance of Citrobacter to such anti-microbials needs extraordinary consideration, particularly in their experimental utilization. As it were one-third of Streptococcus spp. isolates were sensitive to penicillin, erythromycin, vancomycin, and clindamycin. This appeared extraordinary concern for an irresistible condition caused by these bacterial species, such as pneumonia and meningitis. The rise in antibiotic resistance emphasizes the significance of sound healing center disease control, judicious endorsing arrangements, and requirement for modern antimicrobial drugs and immunizations. In common, the current think about appeared that the detailed anti-microbial helplessness information were comparative to the past overall susceptibility design of confines within the consider area [53-55]. In any case, a few of the harmful microbes, such as P. aeruginosa, E. coli, and S. aureus, appeared expanding patterns in resistance [56-58].

Limitations of the study:

Anaerobic bacteria were not included due to infrastructure constraints during the study period.

In conclusion, Gram-negative microscopic organisms were the foremost prevailing isolates from surgical locales within the study site. Among the Gram-negative bacilli, Escherichia coli is the foremost common bacterium causing surgical location disease. A multi-center study ought to be conducted to see the real frequency of resistance isolates among patients with wound contamination. As high anti-microbial resistance was documented within the current study, it is essential to perform schedule microbial examination of tests and their antibiogram. In expansion, we prescribe proper infection anticipation hones to break the malady transmission cycle, reinforcing the accessible antimicrobial stewardship program within the setting, and intermittent antimicrobial observation.

Abbreviations:

CLSI: Clinical and Laboratory Standards Institute; SSIs: Surgical site infections; MDR: Multi- drug resistances.

Acknowledgements:

We would like to express our heartfelt gratitude to the Laboratory technicians and Data Entry personnels of Department of Microbiology and Department of Surgery and patients for their cooperation during data collection.

Funding:

This study was self sponsored by the authors of the manuscript.

Competing interests:

The authors have no competing interests to declare.

1. Horan TC, et al. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol. 1992;13[10):606–8.
2. Mangram AJ, et al. Guideline for prevention of surgical site infection, Infect Control Hosp Epidemiol. 1999;20[4):247–80.
3. Astagneau P, et al. Morbidity and mortality associated withsurgical site infections: results from the 1997–1999 INCISO surveillance. J Hosp Infect. 2001;48[4):267–74.
4. Mukagendaneza MJ, 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):1–8.
5. Coello R, et al. Adverse impact of surgical site infections in English hospi- J Hosp Infect. 2005;60[2):93–103.
6. Plowman R, et al. The rate and cost of hospital-acquired infections occurring in patients admitted to selected specialties of a district general hospital in England and the national burden imposed. J Hosp Infect. 2001;47[3):198–209.
7. Barie PS. Surgical site infections: epidemiology and prevention. Surg Infect. 2002;3[S1):s9–21.
8. Pipaliya B et al. Prevalence of SSI in post operative patients in tertiary health care hospital. Nat J Integr Res Med. 2017;8[2).
9. Attah O et al. Risk factors associated with post-operative infections among orthopaedic patients with clean wounds in OAUTHC, Ile Ife,
10. Nel DC. Surgical site infections. South Afr Family Pract. 2014;56[5):33–7.
11. Sunanthini ARC. Prevalence of nosocomial infection in surgical wounds among postoperative patients and their antimicrobial susceptibility pat- 2015, Madras Medical College, Chennai.
12. Gallo J, Nieslanikova E. Prevention of prosthetic joint infection: from traditional approaches towards quality improvement and data mining. J Clin Med. 2020;9[7):2190.
13. 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.
14. Benito N, et al. Etiology of surgical site infections after primary total joint arthroplasties. J Orthop Res. 2014;32[5):633–7.
15. Cantlon CA, et al. Significant pathogens isolated from surgical site infections at a community hospital in the Midwest. Am J Infect Control. 2006;34[8):526–9.
16. Regmi SM, et al. Bacteriological profile and antimicrobial susceptibility patterns of wound infections among adult patients attending Gandaki Medical College Teaching Hospital, Nepal. J Gandaki Med College-Nepal. 2020;13[1):60–4.
17. Bosco III JA, Mehta SA. Orthopedic surgical site infections: analysis of causative bacteria and implications for antibiotic stewardship. 2014.
18. Anderson DJ. Surgical site infections. Infect Dis Clin. 2011;25[1):135–53.
19. Astagneau P, et al. Reducing surgical site infection incidence through a network: results from the French ISO-RAISIN surveillance system. J Hosp 2009;72[2):127–34.
20. Admassie M, Tsige E, Chanie M. Isolation, identification and antibiotic sus- ceptibility pattern of bacteria isolated from wounds of patients attending at arsho advanced medical laboratory. Science. 2018;7[2):20–4.
21. National Institute for Health and Clinical Excellence. National collaborat- ing centre for women’s and children’s health; Caesarean section: clinical guideline; 2003; pp. 5–17.
22. National Institute for Health and Clinical Excellence. Surgical site infec- tion: prevention and treatment of surgical site infection. 2008; pp. 9–11.
23. Iskandar K, et al. Highlighting the gaps in quantifying the economic burden of surgical site infections associated with antimicrobial-resistant bacteria. World J Emerg Surg. 2019;14[1):50.
24. Laloto TL, Gemeda DH, Abdella SH. Incidence and predictors of surgical site infection in Ethiopia: prospective cohort. BMC Infect Dis. 2017;17[1):119.
25. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infec- tions in the acute care setting. Am J Infect Control. 2008;36[5):309–32.
26. Steel KJ, Barrow G, Feltham R. Cowan and steel’s manual for the identifi- cation of medical bacteria. Cambridge: Cambridge University Press; 1993.
27. Humphries RM et al. CLSI methods development and standardization working group best practices for evaluation of antimicrobial susceptibil- ity tests. J Clin Microbiol. 2018;56[4).
28. Shabnum M. Microbial profile and antibiotic susceptibility pattern of orthopedic infections in a tertiary care hospital: a study from South India. Int J Med Sci Public Health. 2017;6[5):838–42.
29. Mengesha RE, et al. Aerobic bacteria in post surgical wound infections and pattern of their antimicrobial susceptibility in Ayder Teaching and Referral Hospital, Mekelle, Ethiopia. BMC Res Notes. 2014;7[1):1–6.
30. Mohammed A, Adeshina GO, Ibrahim YK. Incidence and antibiotic sus- ceptibility pattern of bacterial isolates from wound infections in a tertiary hospital in Nigeria. Trop J Pharm Res. 2013;12[4):617–21.
31. Shreeram G et al. Bacteriological profile and antibiogram of aerobic wound infection isolates in tertiary health care centre. Int J Med Sci Educ. 2016;3[3).
32. Khanam RA, et al. Bacteriological profiles of pus with antimicrobial sensi- tivity pattern at a teaching hospital in Dhaka City, Bangladesh. J Infect Dis. 2018;5[1):10–4.
33. Maharjan N, Mahawal B. Bacteriological profile of wound infection and antibiotic susceptibility pattern of various isolates in a tertiary care center. J Lumbini Med College. 2020;8[2):7.
34. Pandeya U, et al. Bacteriological profile and antibiogram of bacterial iso- lates from pus samples in tertiary care hospital of Kathmandu. Tribhuvan Univ J Microbiol. 2017;4:55–62.
35. Li G-Q, et al. Epidemiology and outcomes of surgical site infections fol- lowing orthopedic surgery. Am J Infect Control. 2013;41[12):1268–71.
36. Li B, Webster TJ. Bacteria antibiotic resistance: New challenges and oppor- tunities for implant-associated orthopedic infections. J Orthopaedic Res. 2018;36[1):22–32.
37. Godebo G, Kibru G, Tassew H. Multidrug-resistant bacterial isolates in infected wounds at Jimma University Specialized Hospital, Ethiopia. Ann Clin Microbiol Antimicrob. 2013;12[1):17.
38. Azene MK, Beyene BA. Bacteriology and antibiogram of pathogens from wound infections at Dessie Laboratory, North East Ethiopia. Tanzania J Health Res. 2011;13[4).
39. Aye EC et al. Microbiology of wound infections and its associated risk factors among patients of a Tertiary hospital in Benin City, Nigeria. 2011.
40. Patel S, et al. Study of risk factors including NNIS risk index in surgical site infections in abdominal surgeries. Gujarat Med J. 2011;66[1):42–5.
41. Kakati B et al. Surgical site abdominal wound infections: experience at a north Indian tertiary care hospital. Indian Acad Clin Med. 2013.
42. Shahane V, Bhawal S, Lele MU. Surgical site infections: a one year prospec- tive study in a tertiary care center. Int J Health Sci. 2012;6[1):79.
43. Amare B, et al. Postoperative surgical site bacterial infections and drug susceptibility patterns at Gondar University Teaching Hospital, Northwest J Bacteriol Parasitol. 2011;2[8):126.
44. Shriyan A, Sheetal R, Nayak N. Aerobic micro-organisms in post-operative wound infections and their antimicrobial susceptibility patterns. J Clin Diagn Res. 2010;4[6):3392–6.
45. Lubega A, Joel B, X, Justina Lucy N. Incidence and etiology of surgical site infections among emergency postoperative patients in mbarara regional referral hospital, South Western Uganda. Surg Res Pract. 2017.
46. Al-Mulhim FA, et al. Prevalence of surgical site infection in orthopedic surgery: a 5-year analysis. Int Surg. 2014;99[3):264–8.
47. Mardanpour K, et al. Surgical site infections in orthopedic surgery: incidence and risk factors at an Iranian teaching hospital. Clin Trials Orthopedic Disord. 2017;2[4):132.
48. Carvalho RLRd et al. Incidence and risk factors for surgical site infection in general surgeries. Rev Latino-Am Enfermagem. 2017;25.
49. AL-Aali K. Evaluation of surveillance for surgical site infections and drug susceptibility patterns, Taif, Saudi Arabia. Ann Clin Lab Res. 2016;4:2.
50. Tadesse S, et al. Antimicrobial resistance profile of Staphylococcus aureus isolated from patients with infection at Tikur Anbessa specialized Hospi- tal, Addis Ababa, Ethiopia. BMC Pharmacol Toxicol. 2018;19[1):24.
51. Singh R, Singla P, Chaudhary U. Surgical site infections: classification, risk factors, pathogenesis and preventive management. Int J Pharm Res Health Sci. 2014;2:203–14.
52. Abraham Y, Wamisho BL. Microbial susceptibility of bacteria isolated from open fracture wounds presenting to the err of black-lion hospital, Addis Ababa University, Ethiopia. Afr J Microbiol Res. 2009;3[12):939–51.
53. Regasa B, Yilma D, Sewunet T. Antimicrobial susceptibility pattern of bac- terial isolates from community-acquired pneumonia patients in Jimma University Specialized Hospital, Jimma, Ethiopia. 2015.
54. Awoke N, Kassa T, Teshager L. Magnitude of biofilm formation and anti- microbial resistance pattern of bacteria isolated from urinary catheterized inpatients of Jimma university medical center, Southwest Ethiopia. Int J 2019;2019:1–9.
55. Diriba K, et al. In vitro biofilm formation and antibiotic susceptibility patterns of bacteria from suspected external eye infected patients attending ophthalmology clinic, Southwest Ethiopia. Int J Microbiol. 2020;2020:1–12.
56. Mama M, Abdissa A, Sewunet T. Antimicrobial susceptibility pattern of bacterial isolates from wound infection and their sensitivity to alternative topical agents at Jimma University Specialized Hospital, South-West Ethiopia. Ann Clin Microbiol Antimicrob. 2014;13[1):1–10.
57. Gashaw M, et al. Emergence of high drug resistant bacterial isolates from patients with health care associated infections at Jimma University medical center: a cross sectional study. Antimicrob Resist Infect Control. 2018;7[1):1–8.