An Overview of Surgical Site Infection in Low- and Middle-Income Countries: the Role of Recent Guidelines, Limitations, and Possible Solutions

  • Eduardo Rojas-Gutierrez
  • Diana Vilar-CompteEmail author
Treatment and Prevention of Hospital Infections (D Vilar-Compte, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Treatment and Prevention of Hospital Infections


Purpose of review

The purpose of this manuscript is to review preventive strategies for surgical site infection (SSI) in low- and middle-income countries (LMIC) and how the recent World Health Organization (WHO) guidelines, along with the Centers for Disease Control (CDC) recommendations on SSI prevention, may be implemented on these settings, considering frequent limitations and possible solutions.

Recent findings

Surgical site infection (SSI) is the most common postoperative complication and in LMIC is the first cause among healthcare-associated infections (HAI). SSIs are largely preventable if there is a standardized process of care throughout the operative and perioperative period. SSIs, especially clean procedures, are considered a marker of quality in healthcare.


Education and cultural aspects have an enormous influence on the correct performance of SSI preventive measures. Getting patients and healthcare professionals engaged with prevention is the first step to make policies work properly in LMIC, no matter how this might take a lot of time and effort to be accomplished. Infection control professionals are not a luxury in any setting and efforts to support HAI control should be a priority. Surveillance is one of the most important and difficult tasks in SSI prevention.


Surgical site infection Prevention Low and middle income 


Compliance with Ethical Standards

Conflict of Interest

Eduardo Rojas-Gutierrez declares that he has no conflict of interest. Diana Vilar-Compte declares that she has no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    •• Allegranzi B, Kubilay NZ, Zayed B, Atema JJ, Gans S, Boermeester MA, et al. Surgical site infections 1 New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis. 2016;16:e276–87. Key reference for preventing surgical infections. Up-to-date information from the WHO guidelines.CrossRefGoogle Scholar
  2. 2.
    •• Allegranzi B, Bagheri Nejad S, Combescure C, Graafmans W, Attar H, Donaldson L, et al. Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis. Lancet (London, England). 2011;377(9761):228–41. Key reference for preventing surgical infections. Up-to-date information from the WHO guidelines.CrossRefGoogle Scholar
  3. 3.
    • Bhangu A, Ademuyiwa AO, Aguilera ML, Alexander P, Al-Saqqa SW, Borda-Luque G, et al. Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study. Lancet Infect Dis. 2018;18(5):516–25. Manuscript that describes some of the current problems and the impact of surgical site infections in low-, middle-, and high-income countries. Although it only provides information regarding gastrointestinal, it clearly exemplifies the impact of multi-drug-resistant infections and the risk of infection between regions according to income country.CrossRefGoogle Scholar
  4. 4.
    The World Bank. World Bank Country and Lending Groups. Accessed 6 Feb 2019
  5. 5.
    Figueroa-Padilla J, Soto-Perez-de-Celis E, Maciel-Miranda A, Vargas-Salas D, Santamaria E, Esparza-Arias N, et al. Implementation of a microsurgical breast reconstruction program in Mexico. Microsurgery. 2018;38(8):831–3. Scholar
  6. 6.
    Kamat U, Ferreira A, Savio R, Motghare D. Antimicrobial resistance among nosocomial isolates in a teaching hospital in Goa. Indian J Community Med 2008;33(2):89–92.
  7. 7.
    Tessarolo F, Caola I, Caciagli P, Guarrera GM, Nollo G. Sterility and microbiological assessment of reused single-use cardiac electrophysiology catheters. Infect Control Hosp Epidemiol. 2006;27(12):1385–92. Scholar
  8. 8.
    Rönnerstrand B, Lapuente V. Corruption and use of antibiotics in regions of Europe. Health Policy (Amsterdam, Netherlands). 2017;121(3):250–6. Scholar
  9. 9.
    ••Global Guidelines for the prevention of surgical site infection. Geneva: World health organization; 2016.The WHO guideline is a comprehensive review of preventive measures targeted to a wide and general audience.Google Scholar
  10. 10.
    •• Berríos-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, et al. Centers for disease control and prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg. 2017;152(8):784. This paper contains the most current prevention recommendations from the CDC in the USA.CrossRefGoogle Scholar
  11. 11.
    Murillo Llanes J, Varon J, Velarde Félix JS, González-Ibarra FP. Antimicrobial resistance of Escherichia coli in Mexico: how serious is the problem. J Infect Dev Ctries. 2012;6(2):126–31
  12. 12.
    Dubinsky-Pertzov, B., Temkin, E., Harbarth, S., Fankhauser-Rodriguez, C., Carevic, B., Radovanovic, I, Carmeli, Y. (2019). Carriage of extended-spectrum beta-lactamase–producing Enterobacteriaceae and the risk of surgical site infection after colorectal surgery: a prospective cohort study. Clin Infect Dis, 68(10), 1699–1704.
  13. 13.
    Golzarri MF, Silva-Sánchez J, Cornejo-Juárez P, Barrios-Camacho H, Chora-Hernández LD, Velázquez-Acosta C, et al. Colonization by fecal extended-spectrum β-lactamase-producing Enterobacteriaceae and surgical site infections in patients with cancer undergoing gastrointestinal and gynecologic surgery. Am J Infect Control. 2019. 2019 Mar 6. pii: S0196-6553(19)30061-6.
  14. 14.
    Cornejo-Juárez P, Velásquez-Acosta C, Díaz-González A, Volkow-Fernández P. Trend of antimicrobial drug-susceptibility of blood isolates at an oncological center (1998–2003). Salud Publica Mex. 2005;47(4):288–93 Retrieved from Accessed 21 Mar 2019.
  15. 15.
    • Shah KH, Singh SP, Rathod J. Surgical site infections: incidence, bacteriological profiles and risk factors in a tertiary care teaching hospital, western India. International Journal of Medical Science and Public Health. 2017;6:173. This is one of the few papers containing microbiology information from surgical site infections during the last decade.CrossRefGoogle Scholar
  16. 16.
    Humphreys, H., Becker, K., Dohmen, P. M., Petrosillo, N., Spencer, M., van Rijen, M., … Garau, J. (2016). Staphylococcus aureus and surgical site infections: benefits of screening and decolonization before surgery. J Hosp Infect, 94(3), 295–304.
  17. 17.
    Kalra L, Camacho F, Whitener CJ, Du P, Miller M, Zalonis C, et al. Risk of methicillin-resistant Staphylococcus aureus surgical site infection in patients with nasal MRSA colonization. Am J Infect Control. 2013;41(12):1253–7. Scholar
  18. 18.
    Noskin GA, Rubin RJ, Schentag JJ, Kluytmans J, Hedblom EC, Smulders M, et al. The burden of Staphylococcus aureus infections on hospitals in the United States: an analysis of the 2000 and 2001 Nationwide Inpatient Sample Database. Arch Intern Med. 2005;165(15):1756–61. Scholar
  19. 19.
    Chen C-J, Huang Y-C. New epidemiology of Staphylococcus aureus infection in Asia. Clin Microbiol Infect. 2014;20(7):605–23. Scholar
  20. 20.
    How-to guide: prevent surgical site infection for hip and knee arthroplasty. (2012). Cambridge (MA): Institute for Healthcare Improvement. Retrieved from Accessed 19 Mar 2019.
  21. 21.
    Hadiati DR, Hakimi M, Nurdiati DS, da Silva Lopes K, Ota E. Skin preparation for preventing infection following caesarean section. Cochrane Database Syst Rev. 2018;10:CD007462. Scholar
  22. 22.
    WHO guidelines on hand hygiene in health care: first global patient safety challenge clean care is safer care: World Health Organization; 2009. Retrieved from Accessed 16 May 2019.
  23. 23.
    Hamilton HW, Hamilton KR, Lone FJ. Preoperative hair removal. Can J Surg. 1977;20(3):269–71–5 Retrieved from Accessed 1 Apr 2019.
  24. 24.
    Seropian R, Reynolds BM. Wound infections after preoperative depilatory versus razor preparation. Am J Surg. 1971;121(3):251–4 Retrieved from Accessed 16 May 2019.
  25. 25.
    • Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control. 1999;27(2):97–132 quiz 133–4; discussion 96. Retrieved from Accessed 16 May 2019.A must-read manuscript. Contains definitions and recommendations on surgical site infection prevention.
  26. 26.
    •• Allegranzi, B., Zayed, B., Bischoff, P., Kubilay, N. Z., de Jonge, S., de Vries, F., … WHO Guidelines Development Group. (2016). New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis 16(12), e288–e303. World Health Organization publication guidelines that review the best evidence on surgical site infection prevention. Contains an extensive and evidence-based review on the most important risk factors for surgical site infections.
  27. 27.
    Sessler DI. Perioperative thermoregulation and heat balance. Lancet. 2016;387(10038):2655–64. Scholar
  28. 28.
    Melling AC, Ali B, Scott EM, Leaper DJ. Effects of preoperative warming on the incidence of wound infection after clean surgery: a randomised controlled trial. Lancet. 2001;358(9285):876–80. Scholar
  29. 29.
    Wong PF, Kumar S, Bohra A, Whetter D, Leaper DJ. Randomized clinical trial of perioperative systemic warming in major elective abdominal surgery. Br J Surg. 2007;94(4):421–6. Scholar
  30. 30.
    Allen, D. B., Maguire, J. J., Mahdavian, M., Wicke, C., Marcocci, L., Scheuenstuhl, H., Hunt, T. K.. Wound hypoxia and acidosis limit neutrophil bacterial killing mechanisms. Arch Surg 1997; 132 (9): 991–6
  31. 31.
    Ni Y-N, Wang Y-M, Liang B-M, Liang Z-A. The effect of hyperoxia on mortality in critically ill patients: a systematic review and meta-analysis. BMC Pulm Med. 2019;19(1):53. Scholar
  32. 32.
    Abdelmalak B, Abdelmalak JB, Knittel J, Christiansen E, Mascha E, Zimmerman R, et al. The prevalence of undiagnosed diabetes in non-cardiac surgery patients, an observational study. Can J Anesth. 2010;57(12):1058–64. Scholar
  33. 33.
    Dumville JC, Gray TA, Walter CJ, Sharp CA, Page T, Macefield R, et al. Dressings for the prevention of surgical site infection. Cochrane Database Syst Rev. 2016;12:CD003091. Scholar
  34. 34.
    Leaper D, Burman-Roy S, Palanca A, Cullen K, Worster D, Gautam-Aitken E, et al. Prevention and treatment of surgical site infection: summary of NICE guidance. BMJ (Clinical Research Ed). 2008;337(oct28 1):a1924. Scholar
  35. 35.
    • Manivannan B, Gowda D, Bulagonda P, Rao A, Raman SS, Natarajan SV. Surveillance, auditing, and feedback can reduce surgical site infection dramatically: toward zero surgical site infection. Surg Infect. 2018;19(3):313–20. An interesting perspective for surgical site infection surveillance and prevention. Review the importance of surveillance, auditing, and providing feedback to surgeons.CrossRefGoogle Scholar
  36. 36.
    Fakih MG, Heavens M, Ratcliffe CJ, Hendrich A. First step to reducing infection risk as a system: evaluation of infection prevention processes for 71 hospitals. Am J Infect Control. 2013;41(11):950–4. Scholar
  37. 37.
    Guerra J, Isnard M, Guichon C. Postdischarge surveillance of surgical site infections using telephone calls and a follow-up card in a resource-limited setting. J Hosp Infect. 2017;96(1):16–9. Scholar
  38. 38.
    Fukuda H, Kuroki M. The development of statistical models for predicting surgical site infections in Japan: toward a statistical model–based standardized infection ratio. Infect Control Hosp Epidemiol. 2016;37(03):260–71. Scholar
  39. 39.
    Vilar-Compte D, Camacho-Ortiz A, Ponce-de-León S. Infection control in limited resources countries: challenges and priorities. Curr Infect Dis Rep. 2017;19(5):20. Scholar
  40. 40.
    Swaminathan, S., Prasad, J., Dhariwal, A. C., Guleria, R., Misra, M. C., Malhotra, R, … Srikantiah, P. (2017). Strengthening infection prevention and control and systematic surveillance of healthcare associated infections in India. BMJ (Clinical Research Ed), 358, j3768.
  41. 41.
    Wenzel RP. The Lowbury Lecture. The economics of nosocomial infections. J Hosp Infect. 1995;31(2):79–87
  42. 42.
    Fehr, J., Hatz, C., Soka, I., Kibatala, P., Urassa, H., Smith, T, Widmer, A. (2006). Risk factors for surgical site infection in a Tanzanian district hospital: a challenge for the traditional National Nosocomial Infections Surveillance System Index. Infect Control Hosp Epidemiol 27(12), 1401–1404.
  43. 43.
    Nguhuni B, De Nardo P, Gentilotti E, Chaula Z, Damian C, Mencarini P, et al. Reliability and validity of using telephone calls for post-discharge surveillance of surgical site infection following caesarean section at a tertiary hospital in Tanzania. Antimicrob Resist Infect Control. 2017;6(1):43. Scholar
  44. 44.
    Aiken, A. M., Wanyoro, A. K., Mwangi, J., Mulingwa, P., Wanjohi, J., Njoroge, J., … Hall, A. J. (2013). Evaluation of surveillance for surgical site infections in Thika Hospital, Kenya. J Hosp Infect, 83(2), 140–145.
  45. 45.
    Whitby M, McLaws M-L, Doidge S, Collopy B. Post-discharge surgical site surveillance: does patient education improve reliability of diagnosis? J Hosp Infect. 2007;66(3):237–42. Scholar
  46. 46.
    Preventing surgical site infections: implementation approaches for evidence-based recommendations (2018). Geneva, World Health Organization.
  47. 47.
    •Ayub Khan MN, Verstegen DML, Bhatti ABH, Dolmans DHJM, van Mook WNA. Factors hindering the implementation of surgical site infection control guidelines in the operating rooms of low-income countries: a mixed-method study. Eur J Clin Microbiol. 2018;37(10):1923–9. Provides some insights on the difficulties to implement evidence-based prevention strategies in the operating room. Reviews some new aspects on the OR functioning and the implementation of preventive strategies among the anesthesia group.
  48. 48.
    Huskins WC, Soule BM, O’Boyle C, Gulácsi L, O’Rourke EJ, Goldmann DA. Hospital infection prevention and control: a model for improving the quality of hospital care in low- and middle-income countries. Infect Control Hosp Epidemiol. 1998;19(2):125–35. Scholar
  49. 49.
    Licker, M., Bădiţoiu, L., Lungeanu, D., Dobrevska, R., Szilagy, E., Raka, L, … Brusaferro, S. (2017). Infection control capacity building in European countries with limited resources: issues and priorities. J Hosp Infect, 96(1), 85–88.

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Infectious DiseasesInstituto Nacional de CancerologíaMexico CityMexico
  2. 2.Department of SurgeryInstituto Nacional de Ciencias Médicas y Nutrición Salvador ZubiránMexico CityMexico
  3. 3.Departamento de InfectologíaInstituto Nacional de Cancerología (INCan)Mexico CityMexico

Personalised recommendations