Does Prolonged Lenggth Of Stay Increase Risk Of Surgical Sitei Nfection

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Inquiry Article

A Systematic Review of Take a chance Factors Associated with Surgical Site Infections among Surgical Patients

• Ellen Korol,
• Karissa Johnston,
• Nathalie Waser,
• Frangiscos Sifakis,
• Hasan South. Jafri,
• Mathew Lo,
• Moe H. Kyaw

x

• Published: December 18, 2022
• https://doi.org/10.1371/journal.pone.0083743

Figures

Abstract

Importance

Surgical site infection (SSI) complicates 2-5% of surgeries in the United States. Severity of SSI ranges from superficial skin infection to life-threatening conditions such equally astringent sepsis, and SSIs are responsible for increased morbidity, mortality, and economical burden associated with surgery. Staphylococcus aureus (S. aureus) is a normally-isolated organism for SSI, and methicillin-resistant Southward. aureus SSI incidence is increasing globally.

Objective

The objective of this systematic review was to narrate risk factors for SSI within observational studies describing incidence of SSI in a real-world setting.

Evidence Review

An initial search identified 328 titles published in 2002-2012; 57 were identified as relevant for data extraction. Extracted information included study design and methodology, reported cumulative incidence and post-surgical time until onset of SSI, and odds ratios and associated variability for all factors considered in univariate and/or multivariable analyses.

Findings

Median SSI incidence was 3.seven%, ranging from 0.1% to 50.4%. Incidence of overall SSI and S. aureus SSI were both highest in tumor-related and transplant surgeries. Median time until SSI onset was 17.0 days, with longer time-to-onset for orthopedic and transplant surgeries. Risk factors consistently identified as associated with SSI included co-morbidities, advanced historic period, adventure indices, patient frailty, and surgery complexity. 13 studies considered diabetes every bit a hazard factor in multivariable analysis; 85% establish a significant association with SSI, with odds ratios ranging from 1.5-24.iii. Longer surgeries were associated with increased SSI gamble, with a median odds ratio of 2.3 across eleven studies reporting significant results.

Conclusions and Relevance

In a broad review of published literature, risk factors for SSI were characterized as describing reduced fettle, patient frailty, surgery elapsing, and complexity. Recognition of adventure factors oftentimes associated with SSI allows for identification of such patients with the greatest need for optimal preventive measures to exist identified and pre-treatment prior to surgery.

Citation: Korol E, Johnston Thousand, Waser Due north, Sifakis F, Jafri HS, Lo M, et al. (2013) A Systematic Review of Take chances Factors Associated with Surgical Site Infections among Surgical Patients. PLoS ONE 8(12): e83743. https://doi.org/x.1371/journal.pone.0083743

Editor: Asad U Khan, Aligarh Muslim University, India

Received: August xiv, 2022; Accepted: November seven, 2022; Published: Dec 18, 2022

Copyright: © 2022 Korol et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original writer and source are credited.

Funding: The authors have no back up or funding to report.

Competing interests: The authors take the post-obit interests: this report was sponsored by MedImmune, the employer of Frangiscos Sifakis, Hasan Southward. Jafri, Mathew Lo, Moe H. Kyaw at the time of the report. Ellen Korol, Karissa Johnston and Nathalie Waser are employed by Oxford Outcomes, and served every bit consultants for MedImmune in performing this research. There are no patents, products in development or marketed products to declare. This does non change the authors' adherence to all the PLOS ONE policies on sharing data and materials, equally detailed online in the guide for authors.

Introduction

Surgical site infection (SSI) is a unremarkably-occurring healthcare-associated infection, complicating 2-5% of surgeries in the United States (US)[1]. Increased morbidity and mortality are associated with SSI, ranging from wound discharge associated with superficial skin infection to life-threatening conditions such equally severe sepsis[1,two]. SSIs are responsible for an increased economic burden to healthcare systems, including additional postoperative hospital duration and costs[one]. Staphylococcus aureus is a ordinarily-isolated organism in SSI, accounting for 15-20% of SSI occurring in hospital; other organisms regularly isolated from SSIs include gram-negative bacilli, coagulase-negative staphylococci, Enterococcus spp., and Escherichia coli[ane–three]. Methicillin-resistant S. aureus (MRSA) is an increasingly important pathogen that causes more than fifty% of S. aureus infirmary-acquired infections in the U.s.a. and Europe, and presents challenges to treatment due to multiple antibody resistance[4,5].

The risk of developing an SSI is multifactorial. In observational studies, a wider breadth of risk factors and their touch on on incidence of SSI can exist observed based on routine clinical practice, and for a larger range of patients, as opposed to the narrow focus on particular risk factors that may be considered inside clinical trials. Nevertheless, investigators of observational studies cannot control the specific variables and level of detail available and it tin can be challenging to comprehensively suit for all relevant confounding variables in the estimation of particular risk factors for SSI[half-dozen]. To date, overarching syntheses of the data available regarding risk factors for SSI in real world settings has been express.

Equally SSIs keep to pose challenges in healthcare direction, detailed and specific identification of the factors that may place individual patients at greater risk of infection, and identification of the gaps in currently-available prevention options could assist to minimize morbidity, mortality and healthcare costs associated with SSI. The objective of this systematic literature review was to depict the frequency of and factors associated with SSI, S. aureus SSI, and MRSA SSI in a real-world observational setting, every bit they accept been published in the medical, peer-reviewed literature. As the studies included in this review were observational in nature, gamble factors were observed in a real-world setting rather than a randomized controlled trial. The potential for confounding and other sources of bias to have influenced observed results was considered and discussed.

Methods

Search Strategy and Selection Criteria

The methodology for this systematic review was based on the Preferred Reporting Items for Systematic Reviews (PRISMA) reporting guidelines[seven]. Due to the focus of PRISMA guidelines on systematic reviews reporting randomized trial or interventional studies, not all guidelines were relevant to this review of observational studies.

Literature was searched from MEDLINE, EMBASE, the Database of Abstracts of Reviews of Effects and the Cochrane Database of Systematic Reviews. The search strategy was limited to articles published in the English language between 1 January 2002 and 31 May, 2022. This search was supplemented by a PubMed search conducted on 31 May 2022 in order to include the nearly recently published articles indexed within MEDLINE. The search strategy required the broad key terms "Surgical site infection," "Staphylococcus aureus", and "Run a risk factor." Article titles, abstracts and full-texts were assessed by ii independent reviewers against established inclusion criteria; discrepancies between the reviewers were resolved through consensus. Criteria for inclusion, which were applied at all review stages, required that studies: (1) be observational and published in a peer-reviewed periodical, (ii) report a relative consequence for a take a chance factor of SSI mail service-surgery; and (3) talk over South. aureus infections, including but not express to MRSA. Reference lists of included articles were searched for additional relevant sources. Potential eligibility based on inclusion criteria was assessed in a championship review, followed past an abstract review. Manufactures for which the abstruse review suggested potential eligibility were assessed in full-text. For manufactures that were excluded at any phase, the specific reason for exclusion was documented.

Extracted information included study design, institutional factors, baseline population and operative characteristics, incidence of SSI (Due south. aureus, MRSA, superficial incisional-, deep incisional-, and organ-infinite), time until onset of infection, and run a risk gene estimates including odds ratios, conviction intervals and p-values for statistical significance. When information was unclear or missing from a publication, the authors were contacted. In cases where the corresponding author did not respond after multiple contact attempts, the publication was excluded from assay.

Bear witness Synthesis

Study design characteristics and risk factors were summarized as counts and percentages. Inside each study, cumulative incidence was calculated for overall SSI, South. aureus SSI, and MRSA SSI. Cumulative incidence was calculated using a numerator of all identified infections and a denominator of all surgeries eligible for inclusion throughout the follow-upwards menstruation of each study; for the bulk of studies this follow-up period was thirty days for surgeries not involving an implant and one year for surgeries involving an implant. Incidence calculations included multiple surgeries per person for studies in which individuals were eligible to have more than one included surgery and contribute more than than 1 infection to the total count.

When reporting measures of association between risk factors and infection outcomes, a large majority of studies (93%) – both retrospective and prospective – reported odds ratios; while a small number of prospective studies reported relative risks, given the relatively low incidence rates of SSI and the relatively small magnitude of about effect sizes reported here, relative risks tin be interpreted as approximations of odds ratios[viii]; to facilitate synthesis in reporting, all relative effect results were interpreted on the odds ratio scale.

Odds ratios were characterized by the following measures: the number of regression models across studies in which the risk factor was included, the range of estimates across studies, and, amid statistically significant estimates (defined equally p ≤0.05), the number that were identified every bit risk factors (i.e. odds ratio >1.0) vs. protective effects (i.e. odds ratio <one.0). A measure of centrality (e.g. hateful, median) was non reported across studies due to different variable definitions practical beyond studies, such equally continuous vs. categorical variables or different chiselled cutpoints, which forestall numerical estimates from being consistently and meaningfully combined across studies.

Results

A summary of the number of titles, abstracts, and full-text manufactures reviewed, and reasons for exclusion are presented in Figure 1. In addition to post-obit the inclusion criteria set a priori, 4 studies were excluded because of concerns that individuals with SSI may accept been included in the comparison grouping. The findings presenting the fundamental elements of each study included in the systematic review are summarized in Appendix Tabular array S1.

Inside the 57 studies identified for extraction, a number of studies included multiple analyses. For the incidence analysis, sixty unique numerator and denominator estimates were identified across the 57 studies. In the gamble factor assay, the number of models in which each risk factor was included varied beyond specific risk factors; for each factor, the number of models was recorded and this value served as the denominator for related analyses.

An overview of central report characteristics is given in Table 1. A more than comprehensive list of the frequency of specific chance factors is presented in Appendix Table S2. Approximately xc% of studies utilized either a accomplice or case-command design. While individual study designs varied, all studies described a systematic sampling strategy in which all surgeries coming together pre-defined inclusion criteria were considered. There were 25 studies (43.ane%) from the US, and xx studies (35.1%) from Europe or Canada. Four studies were based in East asia, and 8 were from other geographic regions. The median sample size of studies was 437 surgeries, with sample sizes ranging from a prospective accomplice of 15 orthopaedic surgeries in Nihon[nine], to a national surveillance database of over 70,000 surgeries in the Netherlands[10].

	Studies included
	(N=57)
Characteristic	n	%
Study blueprint
Cohort	31	54.4
Case-control	xx	35.1
Nautical chart review	2	3.5
Other	4	7.0
Study perspective1
Prospective	32	56.1
Retrospective	24	42.i
SSI definition
CDC/NNIS	41	71.nine
CDC/NHSN	ane	1.8
Not specified	13	26.3
Other	ii	three.5
Geographical location
Us	25	43.9
Europe/Canadaii	20	35.1
Eastern asia3	4	7.0
Otherfour	8	14.0

Table 1. Characteristics of report design in 57 studies meeting full-text inclusion criteria.

Abbreviations: CDC = Centers for Disease Command and Prevention; NHSN = National Healthcare Rubber Network; NNIS = Nosocomial Infections Surveillance Organisation; due north = number.

¹ One report did non provide enough data to determine if the written report was prospective or retrospective

ⁱⁱ Studies from European countries: Cyprus, England, French republic, Germany, Italy, Serbia, Kingdom of spain, Switzerland, Holland, Turkey and the United Kingdom.

³ Studies from Asian countries: Nihon, Korea and Thailand.

⁴ Studies from other countries: Australia, Brazil, Iran, Mexico, New Zealand, Nigeria, Pakistan and Tanzania.

Cumulative incidence of SSI, overall, and stratified past type of surgery are summarized beyond studies in Table ii and displayed at the individual-written report level in Figure 2. Inside the 57 studies, there were 61 unique reports of overall SSI incidence, 55 studies reported S. aureus incidence and 39 reported MRSA incidence. The median overall SSI cumulative incidence, across all studies, was 3.7%. Incidence ranged from 0.1% to 50.4%; the incidence of 50.4% was observed in a study describing transplant surgery. The surgery types associated with the highest SSI incidence were tumor-related and transplant surgeries; this was true for SSI, S. aureus and MRSA SSI. The median incidence among subgroups of SSI was 2.two% for superficial infections (29 studies), one.2% for deep incisional infections (31 studies), and 0.vi% for organ-space infections (15 studies).

Surgery blazon	% Incidence of infection: Median (Range)						Time to SSI onset (days post-surgery): Median (northward=17)
	SSI (due north=60)		Southward. aureus SSI (northward=55)		MRSA SSI (due north=39)
Overall (n=61)1	3.7	(0.1 - 50.4)	1.8	(0.one - 56.0)	0.eight	(0.0 - 32.0)	17.0	(half-dozen.ii - 41.4)
Surgery blazon
Mixed surgeries (n=11)	1.9	(0.1 - 26.0)	ane.5	(0.1 - 6.4)	0.5	(0.1 - ten.2)	7.2	(vi.2 - 8.2)
Cardiothoracic (n=14)	ii.8	(0.5 - 16.iv)	ane.3	(0.iii - 56.0)	0.5	(0.0 - 32.0)	9.9	(9.0 - 17.0)
Neurosurgery (n=7)	4.2	(ane.ane - 9.4)	2.3	(0.6 - 5.5)	0.7	(0.one - 1.1)	xv.0	(13.5 - 20.v)
Tumor-related surgery (due north=v)	17.0	(ix.6 - 27.5)	6.one	(1.ix - xi.9)	1.3	(ane.3 - ane.3)	17.9	(17.0 - 34.0)
Orthopedics (n=19)	2.7	(0.6 - 12.2)	1.6	(0.4 - 4.four)	0.8	(0.iii - ii.5)	33.5	(13.5 - 41.4)
Transplant (n=4)	vi.8	(4.eight - 50.4)	4.viii	(1.0 - 15.0)	6.iii	(1.0 - eleven.five)	41.0	(41.0 - 41.0)
Gastric (n=i)	four.0	(iv.0 - four.0)	0.5	(0.5 - 0.5)	0.4	(0.four - 0.4)	8.0	(eight.0 - viii.0)

Table 2. Incidence of surgical site infections and time until infection onset as reported in 60 analyses performed across 57 studies¹.

Abbreviations: MRSA = methicillin-resistant Staphylococcus aureus; MSSA = methicillin-susceptible Staphylococcus aureus; northward = number; S. aureus = Staphylococcus aureus; SSI = surgical site infection.

ⁱ Fifty-seven studies were included, still Ridgeway et al.[64] and Gupta et al.[52] reported cumulative incidence multiple analyses.

² Restricted to studies reporting foreign trunk medical devices that were permanently implanted during surgery.

Seventeen studies reported fourth dimension until onset of SSI with a median overall time of 17.0 days post-surgery, ranging from 6.two to 41.iv days. Time until onset tended to exist highest in orthopedics and transplant surgeries, potentially due to risk of delayed infection associated with implantation of a foreign object.

Unadjusted and adapted odds ratios are presented in Table iii for key adventure factors that were either identified a priori as existence of particular interest or noted as frequently reported across studies. Variables that were about consistently found to have odds ratios >1 for all infections (i.eastward. SSI, S. aureus SSI and MRSA SSI) in both unadjusted and adjusted analyses included increasing torso mass alphabetize (BMI), more severe derived run a risk indices, more than severe wound grade, diabetes condition, and increased surgery duration. Other factors such as increased patient dependence, smoking status, increasing age, S. aureus colonization, and employ of medical device, were significantly associated with increased risk of all SSIs (i.east. SSI, Southward. aureus, and MRSA SSI) in adjusted analyses. While five studies reported statistically meaning unadjusted associations and six studies reported statistically significant adjusted associations between SSI and prophylaxis (Table 3), the bulk of these represent comparisons beyond alternative prophylaxis regimens as opposed to comparing of any prophylaxis use vs. none; one study reported an association between antibiotic prophylaxis and increased odds of SSI[11]; nevertheless that report was not corroborated by other studies.

	n regression models reported	Range of estimates	n (%) models with statistically meaning estimatesone
Risk gene			Risk factors		Protective upshot
Unadjusted results
Female gender	31	0.iv - three.five	5	(16.1)	4	(12.nine)
Increasing age	21	0.6 - viii.5	9	(42.9)	1	(4.viii)
Increasing BMI	23	0.4 - nine.eight	12	(52.2)	0	(0.0)
More than severe ASA score	19	0.5 - 44.viii	12	(63.2)	0	(0.0)
More severe NNIS score	5	0.7 - four.3	4	(80.0)	0	(0.0)
Diabetes	24	0.7 - 29.6	ten	(41.seven)	0	(0.0)
Smoking status	xi	0.3 - 27.0	2	(18.two)	2	(18.2)
Increased patient dependence	5	0.4 - 6.3	4	(lxxx.0)	1	(20.0)
South. aureus colonization	seven	0.0 - 15.5	five	(71.iv)	ane	(fourteen.3)
Increased length of hospital stay	ten	one.0 - 12.9	vii	(70.0)	0	(0.0)
Use of medical device3	4	0.3 - v.vi	1	(25.0)	i	(25.0)
More severe wound class	fourteen	1.0 - 17.4	9	(64.3)	0	(0.0)
Increased surgery elapsing	19	0.7 - 9.0	12	(63.two)	0	(0.0)
Prophylaxis	16	0.6 - 18.1	5	(31.3)	0	(0.0)
Adjusted results
Female person gender	14	0.4 - iii.3	v	(35.7)	2	(fourteen.3)
Increasing age	xv	one.0 - 14.0	x	(66.seven)	0	(0.0)
Increasing BMI	twenty	1.0 - 7.1	17	(85.0)	0	(0.0)
More than severe ASA score	7	0.7 - 4.2	3	(42.ix)	0	(0.0)
More severe NNIS score	5	1.4 - 4.7	3	(sixty.0)	0	(0.0)
Diabetes	12	1.v - 24.iii	eleven	(91.seven)	0	(0.0)
Smoking status	three	ane.two - 16.8	two	(66.seven)	0	(0.0)
Increased patient dependence	4	0.0 - 4.4	3	(75.0)	0	(0.0)
S. aureus colonization	7	0.7 - 12.5	v	(71.4)	0	(0.0)
Increased length of infirmary stay	five	0.8 - 10.seven	5	(100.0)	ane	(20.0)
Apply of medical device2	two	4.0 - 670.iv	2	(100.0)	0	(0.0)
More astringent wound class	10	i.7 - 10.7	eight	(80.0)	0	(0.0)
Increased surgery elapsing	12	0.1 - 3.ii	8	(66.7)	0	(0.0)
Prophylaxis	7	0.4 - twenty.5	half dozen	(85.7)	0	(0.0)

Table 3. Odds ratio ranges for estimates of key risk factors for all SSIs, stratified by unadjusted and adapted methods.

Abbreviations: ASA = American Guild of Anesthesiologists; BMI = torso mass index; ICU = intensive care unit; NNIS = National Nosocomial Infections Surveillance; n = number; OR = odds ratio; S. aureus = Staphylococcus aureus.

¹ Statistical significance defined equally p ≤0.05

² Restricted to studies reporting foreign body medical devices that are permanently implanted during surgery

Twenty-five studies assessed the human relationship between derived risk indices such as the Charlson, National Nosocomial Infections Surveillance (NNIS), or American Society of Anesthesiologists (ASA) indices, and gamble of SSI (Figure 3). A number of estimates failed to reach statistical significance (Tabular array 3), although a big bulk of unadjusted and adjusted point estimates indicated a trend towards increased take chances. Most estimates were based on a unmarried cutpoint to create a binary indication of loftier vs. depression risk score; however, some estimates were based on the original multi-level scales and indicated a dose-response relationship for the NNIS[12,13] and Charlson[14] indices.

Co-morbidities were consistently found to be associated with SSI incidence. The most oft considered co-morbidity was diabetes, which was included in thirteen adapted analyses, and 85% of these reported a statistically significant association. Other co-morbidities for which significant adjusted associations were found included chronic obstructive pulmonary disease (COPD)[fifteen–18], coronary center disease[17], congestive heart failure[19], astute myocardial infarction[xx], renal insufficiency[19], hypertension[21] and osteoporosis[17]. The relationship between increasing number of comorbidities and SSI was assessed in several studies. In unadjusted analyses, iv studies reported a statistically significant clan betwixt increasing number of co-morbidities and SSI[17,22–24], and three studies reported statistically significant adjusted results[22–24]. In adjusted analyses, increasing number of co-morbidities was associated with an estimated odds ratio for SSI of i.7 (95% CI: i.3-2.ix) per co-morbidity[24], and presence of at to the lowest degree one co-morbidity was associated with an estimated odds ratio for SSI of 2.three (95% CI: 1.2-4.vii)[22] in spinal surgeries and 6.i (95% CI: 1.iii-28.9) in all major surgeries[23].

Ten studies considered hazard factors describing patient dependence and frailty, which were characterized in a diverseness of ways, including independence and activities of daily living[14,fifteen,25–27], incontinence[xv,25,28], and admission from a long-term health-intendance facility[xiv,27]. The bulk of these factors were only considered in unadjusted analyses; adjusted estimates include an odds ratio for SSI of 4.35 (95% CI: ane.64-11.11) associated with admission from a long-term health facility[27], and an odds ratio for SSI of 2.75 (95% CI: 1.16-six.46) associated with requiring aid with three or more activities of daily living[25].

Variables describing the complication and/or duration of surgery were as well found to be associated with risk of SSI in 16 studies. Duration was defined either relative to a cutpoint (eastward.yard. 75^th percentile, 120 minutes, 180 minutes), as a continuous measure per minute of surgery, or as a multi-level categorical variable. Across definitions, increased duration of surgery was consistently plant to exist associated with increased chance of SSI. When results were restricted to 16 studies that used a binary cutpoint to compare shorter vs. longer surgeries, 15 of sixteen estimates suggested an increased adventure of SSI for longer surgeries[12,14,15,22,23,25,27,29–36]; 11 of these were statistically pregnant, with estimated odds ratios ranging from 1.2 to 3.eight with a median value of 2.iii.

Pre-operative length of stay was identified every bit a significantly associated risk factor for SSI in 12 studies[3,11–fourteen,23,29,33,36–39]. Odds ratios for SSI per additional solar day of pre-operative stay ranged from 1.0 to 2.0, with a median of ane.1[eleven,12,14,36–38]. Odds ratios associated with surgeries requiring a prior overnight stay were estimated to be ane.4[15] and 4.half dozen[29]. Ane study plant that pre-operative hospitalizations of up to seven days were not associated with a significant risk of SSI, just that pre-operative stays of eight days or longer were associated with an approximate 10-fold increased risk of SSI[39].

Discussion

In this broad review of the published literature, a number of gamble factors for overall SSI, Southward. aureus SSI, and MRSA SSI were identified; these included variables describing reduced patient fitness such as co-morbidities, advanced age, take chances indices (ASA or NNIS), increased BMI, and patient dependence. Other important markers included increased length of pre-operative infirmary stay, and surgery complexity including increased surgical time. Identified risk factors are biologically plausible, suggesting that patients who are less fit, who have a greater in-hospital exposure fourth dimension, and/or are undergoing longer and more complex surgeries are at an increased risk for SSI. A statistically meaning clan between antibody prophylaxis and increased risk of SSI observed in one study lacks biologic plausibility every bit a causal human relationship given well-documented prove regarding a protective effect of antibiotics for SSI[40,41], and increased risks documented in observational studies may be a outcome of misreckoning by indication, eastward.m. due to increased antibiotic employ in patients accounted to exist at loftier adventure for infection, in more complex surgeries, or in surgeries for which medical errors may have occurred[42,43].

As has been noted previously, generating estimates across studies is challenging due to variation in written report characteristics, variable definition, specific surgeries included, and study quality[44,45]. Equally such, overall trends in take a chance factors were assessed, focusing on direction of effect and achievement of statistical significance, rather than quantitative synthesis across estimates which are not straight comparable. Where applicable, subsets of studies that characterized risk factors using comparable definitions were pooled to generate summary estimates. In addition to variables reported every bit risk factors for SSI within individual studies, a written report-level comparison of reported cumulative incidence (Table 2) provides further insight into surgical-level risk factors, as some studies focused on specific types of surgery. These results suggest that the highest rates of infection are observed in tumor-related surgeries and transplant surgeries; however these are based on observed results across relatively small numbers of studies rather than formal statistical comparisons, and can be interpreted only as exploratory evidence.

Despite widespread adoption of preventive measures by institutions, SSIs continue to occur, and, while the results presented hither do not call into question recommendations for existing prevention options, they do suggest a remaining gap and a potential benefit of additional options to further reduce SSI incidence in high-risk patient subgroups. Given that specific patient-level and operative-level chance factors accept been consistently observed across studies, and the availability of formal risk indices such as ASA and NNIS scores for identifying high-risk patients, those patients with the greatest need for optimal preventive measures can be identified prior to surgery.

Strengths of this review include the comprehensive nature of report eligibility and run a risk factor consideration. All observational studies reporting risk factors for SSI across all types of surgery were considered for inclusion, and all risk factor estimates were extracted from each study, giving a broad view of gamble factors as observed in routine clinical exercise across a diverseness of settings. Given the variation in studies, a number of stratified analyses were performed to compare results against specific study characteristics, including surgery blazon, geography, and population characteristics; nevertheless, broad trends remained consistent in these stratified analyses and further estimation was limited due to minor study-numbers; these results are not included here. The comprehensive nature of the review also led to limitations; a broad collection of studies with variability in methodology and run a risk factors considered were included in the review, which presented challenges in numeric synthesis of results. Every bit such, results are primarily focused on the direction of effect, as opposed to magnitude. A more narrow focus on specific risk factors would allow for more detailed exploration of individual trends and magnitude of effect across studies. Results were presented to summarize the entire range of studies, and differences in sample sizes were non accounted for in the synthesis of results.

While the variability across studies express the ability to generate a single quantitative estimate for specific take chances factors, it also provides strength in evidence of the direction of effect for factors such as co-morbidity burden, patient dependence and frailty, and duration and complexity of surgery, which were consistently institute to be associated with an increased take a chance of SSI, across a diverseness of report designs, study settings, and variable categorizations and definitions.

Supporting Information

Acknowledgments

The authors wish to acknowledge Dr. Adrian Levy for providing valuable methodological input into the study and thank Kellie Ryan and Parthiv Mahadevia for their thoughtful review of the manuscript.

Author Contributions

Conceived and designed the experiments: EK KJ NW FS HSJ ML MHK. Analyzed the data: EK KJ NW. Wrote the manuscript: EK KJ NW FS HSJ ML MHK.

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Does Prolonged Lenggth Of Stay Increase Risk Of Surgical Sitei Nfection,

Source: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0083743

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