Sustainable Surgical Site Infection Prevention in LMIC: Persistence of a Limited Intervention in a Kenyan Hospital

Author(s):
Angie Sway; Anthony Wanyoro; Alexander Aiken; Joseph Solomkin

Background:

Surgical site infections (SSI’s), which account for up to one third of all hospital acquired infections (HAI), are a crucial public health challenge. Efforts to minimize SSI’s must not only be effective, but also sustainable, particularly in low- and middle-income countries. Recent prevention tactics have trended toward bundled interventions and multi-disciplinary programs that focus as much on changing the culture around surgical safety as explicit practical recommendations. While these programs have been shown to be effective in high-income, well-established hospitals, it is unclear whether they will be superior to simpler “limited intervention” efforts in low resource setting.

Hypothesis:

We believe that limited, practical interventions are better suited for facilities in low- and middle-income countries than bundled, unit-based interventions.

Methods:

A program for SSI prevention consisting of SSI surveillance and a single intervention to administer antibiotic prophylaxis immediately before all surgical operations was developed and implemented at a Government hospital in Kenya.Surveillance was conducted between August 2010 and November 2011, and policy implementation began in February 2011. An observational study was conducted at two Kenyan Hospitals, including the Government Hospital that participated in the 2010 study (Hospital A), between September and December 2015 to collect data on the incidence and risk factors for post-cesarean SSI in 609 women.

Results:

Prior to implementation of the policy in 2011 to change the timing of antibiotic prophylaxis, approximately 99% of patients at Hospital A were exclusively administered post-operative antibiotics; in 2015, all patients at Hospital A received antibiotic prophylaxis no more than 120 minutes before their operation. Patients at Hospital B were demographically comparable to those at Hospital A, but were given only post-operative antibiotics according to hospital policy. The SSI rate was 4.0% (12/299; 11 superficial SSI, 1 deep SSI) at Hospital A and 9.3% (28/301; 18 superficial SSI, 7 deep SSI, 3 organ/space SSI) at Hospital B.

Conclusions:

The policy change at Hospital A was found to have persisted well beyond the study period. We believe that the success and sustainability of this policy was in large part due to local engagement through the development and implementation process, extensive staff training and support, and the presence of a strong policy champion at the hospital. As this limited-intervention model has been shown to be both effective and sustainable for hospitals in low- and middle-income regions, we would recommend it’s use in future infection prevention efforts in these settings.