Background: The incidence of surgical site infections (SSI) must be determined to help decision-makers better plan and execute surgical care by gauging the severity of the problem. OBJECTIVES: The meta-analysis aims to determine the risk factors for SSI in general surgical patients undergoing appendectomy and to estimate the incidence of SSI in the Indian subcontinent population. Materials And Methods: To find cross-sectional, cohort, Rct’s, and observational studies reporting SSI incidence or prevalence, a systematic review was conducted using PUBMED, MEDLINE, EMBASE, and the Cochrane Library. Excluded were studies with fewer than 40 participants. Two review authors worked independently to extract the data and evaluate its quality. The cumulative incidence of SSI occurring up to 30 days postoperatively was the main outcome. Random effects models were applied when there was a significant amount of heterogeneity. Subgroup and sensitivity analyses of meta-regression were employed to investigate the sources of heterogeneity. Results: 18 studies were included out of the 231 publications retrieved. The meta-analysis included 18 studies covering three countries and 4924 patients. The cumulative incidence of SSI was 5.25% (95% CI 0.4-16.2). There were no data on prevalence identified. SSI rates varied depending on a geographical location, surgical approach, and priority (planned or emergency). A multivariable meta-regression revealed a significant correlation between appendectomy and incidence of SSI (estimate 2.2, 95% CI 1.11-2.42, P =0.019). Conclusion: This systematic review and meta-analysis, which revealed a significant prevalence of SSI following appendectomy is 5.25 per 100 appendectomies. These findings imply that a lower incidence of SSI following appendectomy is linked to less invasive procedures. To reduce the harm caused by SSI, high-quality studies are needed to better understand the patient and associated risk factors.
Appendicitis widespread abdominal illness with relevant morbidity, mortality, and substantial medical expenses. The pooled incidence of appendicitis in the Indian subcontinent ranges from 100 to 105 cases per 100,000 person/year, with a rising incidence trend in newly industrialized countries, according to a systematic review of population-based studies. The preferred treatment for appendicitis is an appendectomy, which is performed worldwide and places a heavy burden on health systems. The majority of patients with appendicitis are in their second or fourth decade of life, with a median age of 22 and a mean age of 31.3. A slight male-to- female ratio (1.2 to 1.3:1) is present. After an appendectomy, surgical site infection (SSI) is a frequent consequence, particularly in cases of complicated appendicitis.[1] Though SSIs are the most common infections linked to health care in developing nations, the WHO has provided a wide range of evidence-based recommendations for interventions to be applied during the pre-op, intra-op, and postoperative periods for the prevention of SSIs, such as preoperative bathing and maintaining normal body temperature. According to a recent meta-analysis, the incidence of SSI varied from 0 to 17.4 per 100 appendectomies, with an overall value of 6.2. This result suggested that, following an appendectomy, SSI is highly prevalent in the Indian subcontinent following appendectomy[3]. Similar to the normal colon, the normal appendix has a similar bacterial population. With Porphyromonas gingivalis as the exception, the appendix flora does not change during life. This particular bacterium is unique to adults. As a result, the bacteria cultivated from appendicitis cases are comparable to those from other colon infections like diverticulitis [2]. Escherichia coli and B. fragilis, are the main microorganisms found in the normal appendix, acute appendicitis, and perforated appendicitis. Nonetheless, various facultative, anaerobic, and mycobacteria may exist. A polymicrobial infection, appendicitis has been shown in some series to harbor up to 14 distinct organisms in the cultures of patients who have had perforations.
There are several ways that appendix acute inflammation can manifest[5]. A histopathological criterion for diagnosing acute appendicitis is the presence of polymorphous leucocytic infiltration within the muscularis mucosa. Murphy (1805) provided a clear description of the proper progression of symptoms, which included pain, nausea, vomiting, fever, and exaggerated local tenderness in the appendix's position.[6] A patient with acute appendicitis may present with Murphy's triad of pain, vomiting, and fever. These days modified Alvarado scale is being used to evaluate signs of appendicitis (tab.1)[4]. The current study's objective is to investigate the incidence of surgical site infection after appendectomy in the Indian subcontinent.
OBJECTIVES:
The meta-analysis aims to determine the risk factors for SSI in general surgical patients undergoing appendectomy and to estimate the incidence of SSI in the Indian subcontinent population.
Data extraction
Using standardized definitions, PubMed, Google Scholar, and EMBASE were searched for studies that documented the incidence of SSI following appendectomy and were published between January 1, 1995, and January 31, 2024. The Centre for Disease Control revised and released standardized definitions of SSI. Two investigators decoded and analyzed data from the included studies using a standardized data collection form. Extracted data included the first author, publication year, nation, population, sample size, surgical technique (laparoscopy or open), the incidence of SSI in laparoscopy and open appendectomy, and SSI rates.
We considered observational studies (cross- sectional, randomized control trials, case– control, and cohort) and clinical trials of appendectomy patients. The outgrowth of interest was the prevalence of SSI in cases witnessing appendectomy (or enough data to cipher this estimate, i.e. number of cases of SSI and sample size). We barred those studies that demanded crucial data and or unequivocal system description letters, reviews, narrative studies as well as studies where applicable data on SSI after appendectomy were insolvable to prize indeed after reaching the corresponding author.
Data Analysis
Combining data from various studies reporting the incidence of SSIs, a meta-analysis was utilized to summarize data on the incidence of SSIs. After using the Freeman-Tukey double arc- sine transformation to stabilize the variance of each study and the incidence across studies. The 95% confidence interval for 100 appendectomy surgical procedures was used to express the incidence. When significant heterogeneity (I2>50%) was found, a subgroup analysis was carried out using the following grouping factors to identify potential causes: WHO area, and type of surgery (laparoscopy or open). Statistical significance was indicated by a p-value less than 0.05. To determine how much of each covariate in the subgroup analysis might be explained by heterogeneity, a meta-regression analysis was conducted. We have not supplied adjusted incidence estimates in the event of publication bias because we believed that the incidence estimates of interest would be reported even if they differed significantly from previously reported estimates because of the low volume of the studies included. Data were analyzed using the Revman V.5.1.[29]
Figure-1: Study Flow According To Prisma Guidelines.
In all, 231 records were found at first. Once duplicates were eliminated and research titles, abstracts, and full texts were screened,160 papers were screened for inclusion and exclusion criteria which yielded 18 papers with 4924 patients left for meta-analysis. Overall, India (n = 11), Pakistan (n = 4), Bangladesh (n=2), and Thailand (n=1) accounted for the majority of the studies. Eight research studies classified SSI using the criteria set forth by the Centre for Disease Control and Prevention; the remaining 10 studies utilized different standards.[7]
TABLE -2 ANALYSIS OF STUDIES WITH THE SSI RATE OF INCIDENCE IN THE INDIAN SUBCONTINENT
S.N O |
AUTHOR AND YEAR |
NATI ON |
PERIOD |
DESIGN |
POPULATION |
TYPE OF SX |
SAMPLE SIZE [OPEN/LAP] |
INCIDENCE IN OPEN SX [%] |
INCIDENCE IN LAP SX [%] |
TOT SSI |
1 |
KUMAR ET AL 2016[11] |
INDIA |
2014-16 |
RCT |
ADULT/PEDIA /ELDERLY |
LAP/OPEN |
111(42/69) |
4 |
1 |
5 |
2 |
AKHILESH ET AL 2023[13] |
INDIA |
2019-22 |
RCT |
ADULT/ ELDERLY |
LAP/OPEN |
100(95/5) |
12 |
1 |
13 |
3 |
MUHAMMED ET AL 2016[14] |
PAKIS TAN |
2012 |
RCT |
ADULT/PEDIA/ ELDERLY |
LAP/OPEN |
200(100/100) |
10 |
1 |
11 |
4 |
PANDEY ET AL 2018[10] |
INDIA |
2015-17 |
RCT |
ADULT /PEDIA |
LAP/OPEN |
132(65/30) |
11 |
1 |
12 |
5 |
SIDDIQUE ET AL2016[9] |
INDIA |
2015-17 |
RCT |
ADULT/PEDIA |
LAP/OPEN |
196(NR) |
NR |
NR |
16 |
6 |
KULDEEP ET AL 2023[24] |
INDIA |
NR |
RCT |
ADULT/PEDIA /ELDERLY |
LAP/OPEN |
62(40/22) |
6 |
1 |
7 |
7 |
PUJAR ET AL 2018[23] |
INDIA |
2017 |
OBSERVAT IONAL |
ADULT/PEDIA |
LAP/OPEN |
50(NR) |
NR |
NR |
15 |
8 |
KASTPIBAL ET AL 2006[22] |
THAIL AND |
2003-04 |
COHORT |
ADULT/PEDIA/ ELDERLY |
LAP/OPEN |
2139(NR) |
NR |
NR |
26 |
9 |
GNANARAJ ET AL 2015[21] |
INDIA |
2012- 2014 |
COHORT |
ADULT/PEDIA/ ELDERLY |
LAP/OPEN |
104(0/104) |
0 |
7 |
7 |
10 |
MALIK ET AL 2009[20] |
PAKIS TAN |
2003-07 |
RCT |
ADULT/PEDIA/ ELDERLY |
LAP/OPEN |
283(150/133) |
14 |
2 |
16 |
11 |
KHALIL ET AL 2010[19] |
PAKIS TAN |
2008-09 |
RCT |
ADULT/PEDIA/ ELDERLY |
LAP/OPEN |
147(75/72) |
3 |
8 |
11 |
12 |
KHIRIA ET AL 2011[18] |
INDIA |
1999- 2009 |
RETROSPE CTIVE |
ADULT/PEDIA/ ELDERLY |
LAP/OPEN |
119(19/100) |
11 |
8 |
19 |
13 |
UTPAL ET AL 2005[17] |
INDIA |
NR |
RCT |
ADULT/PEDIA/ ELDERLY |
LAP/OPEN |
279(179/100) |
25 |
4 |
29 |
14 |
GUNDAVADA ET AL 2012[15] |
INDIA |
2012 |
RCT |
ADULT/ ELDERLY |
LAP/OPEN |
60(30/30) |
5 |
2 |
7 |
15 |
SALIM ET AL 2017[16] |
BANG LADE SH |
2015-16 |
OBSERVAT IONAL |
ADULT/ ELDERLY |
LAP/OPEN |
200(100/100) |
14 |
10 |
24 |
16 |
SHEYTE ET AL 2022[12] |
INDIA |
2019 |
OBSERVAT IONAL |
ADULT/ ELDERLY |
LAP/OPEN |
42(NR) |
NR |
NR |
2 |
17 |
SHAIK ET AL 2009[25] |
PAKIS TAN |
2003-06 |
RCT |
ADULT/ ELDERLY |
LAP/OPEN |
100(52/48) |
8 |
3 |
11 |
18 |
RAHMAN ET AL 2013[26] |
BANG LADE SH |
2004-10 |
RCT |
ADULT/PEDIA/ ELDERLY |
LAP/OPEN |
600(340/260) |
20 |
8 |
28 |
There was significant heterogeneity and publication bias, with an overall incidence of SSI following appendectomy of 5.25 per 100 appendectomies (95% CI: 0.4–16.2), ranging from 4% to 21.4%. Compared to laparoscopic appendectomy, which had an incidence of 4.8 (95% prediction interval: 0.0–9.3) per 100 appendectomies, open appendectomy was shown to have a higher incidence of SSI, since most of the complicated appendicitis were operated by open approach. Its incidence was 10.5 (95% prediction interval: 0–23.3) per 100 appendectomies.
Figure 2: Forrest Plot Of The Studies Showing Incidence Of Ssi:
The plotted studies showed a positive relation between the incidence of SSI following appendectomy.[9-26]
We observed trends and variances in the Indian subcontinent about the burden of appendicitis in this analysis. We demonstrated that the majority of studies with consistent definitions of surgical site infections (SSIs) following appendectomy have shown greater rates of SSI were linked to open appendectomy; Planning the use of health care resources requires data on the burden of appendicitis and SSI from an appendectomy, and to our knowledge, this is the first research to be done in the Indian subcontinent based on the SSI standard definition to evaluate the incidence of appendicitis.
A significant prevalence of SSI following appendectomy was also found in a meta-analysis of 18 studies (5.25 per 100 appendectomies). Worldwide, the most common adverse event compromising patient safety is healthcare-associated infection, which is contracted by patients while getting care. One of these is SSI following an appendectomy.[3] In industrialized nations, SSI was the most common infection in hospitals, as previously documented in a systematic review and meta-analysis. The elevated frequency seen in this investigation implies that SSI following appendectomy continues to be a worldwide public health issue.
The primary cause of SSI is microorganisms that are resistant to standard antimicrobials and may even be multidrug resistant. Antibiotic resistance can indeed occur in over 50% of SSI. Staphylococcus aureus, coagulase-negative staphylococci, and Escherichia coli are the most common microorganisms found in surgical site infections (SSIs), according to the National Healthcare Safety Network study. Many factors can Favor SSI, including patient-related and procedural-related factors. These factors can be divided into non-modifiable factors like age and sex, and modifiable factors like nutritional status, tobacco use, correct use of antibiotics, obesity, diabetes, prolonged duration of surgery, and pre- surgery hospital stay. It is concerning because S. aureus and E. coli are the microorganisms with the highest proportion of antibiotic resistance, respectively resistant to cloxacillin/methicillin in 43% of cases and to fluoroquinolones in 25% of cases. A recent international study has shown that 21.6% of patients with SSI after any GI surgery had an infection that was resistant to the antibiotics used for prophylaxis.[8],[28] Nonetheless, several single, multicentred investigations as well as meta-analyses have demonstrated associations between elevated SSI and open appendectomy. We verified the relationship between surgical modalities/types of appendicitis and SSI of appendectomy by concentrating on studies with standardized SSI definitions. This further suggests that the development and promotion of laparoscopic procedures help lower the SSI of appendicitis, particularly in the Indian subcontinent [27].
The prevalence of appendicitis is a widespread local and international health problem, with a somewhat unequal disease burden distribution worldwide. The variation in appendicitis burden between locations may be partially explained by variations in medical practices, such as surgical technique, medical therapy, and diagnostic modalities, in addition to population- and genetic-related variables.[7] The establishment of SSI special management at the national or regional level may be more effective in reducing SSI incidence, given area variations and resource availability. Socioeconomic development is also linked to geographic disparities in appendicitis because more developed countries are thought to have better healthcare systems and higher levels of medical technology.[2]
LIMITATIONS:
Various drawbacks should be taken into consideration while interpreting this study. Initially, the included research defined SSIs differently. Furthermore, there was considerable variation in the patient profile and the surgical technique. Individual studies may have overestimated or underestimated the incidence of SSI due to this, depending on the specific research parameters. Second, the characteristics of the participants and the specifics of the surgical process, which might alter the risk of acquiring SSIs, were not well documented in the research. As a result, we were unable to gauge their influence on our desired result. Yet, when we limited our analysis to studies with such a risk, the result was an estimate that was quite similar to the crude incidence.[29}
Data from around 5000 appendicitis patients from four countries were gathered for this systematic review and meta-analysis, which revealed a significant prevalence of SSI following appendectomy is 5.25 per 100 appendectomies. These findings imply that a lower incidence of SSI following appendectomy is linked to less invasive procedures. To reduce the burden of SSI following appendectomy, strategies are required to put established principles into practice. However, cost- effectiveness studies are required to guide governments on the best measures to reduce the burden of SSI following appendectomy in low- income countries with underdeveloped health systems.[8]
There is still a high prevalence of appendicitis in nations with limited resources, and there are no standard surveillance criteria for SSI. Our primary goal should be to lower the prevalence of SSI and other diseases in developing nations. This may be achieved by promoting laparoscopic technology, creating SSI special management programs, and standardizing the description of SSI.
Funding: No particular grant from a governmental, private, or nonprofit organization has been disclosed by the authors for this research.
Conflicting interests: none were mentioned. Publication permission from patients: not necessary.
Data availability statement: All study-related data are uploaded as supplemental material or are provided in the publication.