Postoperative infection and

mortality following elective

surgery in the International
Surgical Outcomes Study (ISOS) !
Y I Wan # , Akshaykumar Patel, C Achary, R Hewson, M Phull,
R M Pearse,
the International Surgical Outcomes Study (ISOS) Group
Author Notes

British Journal of Surgery, Volume 108, Issue 2, February

2021, Pages 220–227, https://doi.org/10.1093/bjs/znaa075
Published: 18 January 2021 Article history "

Abstract
Background
Postoperative infection is one of the most frequent
and important complications after surgery. The
epidemiology of infection following elective surgery
remains poorly described.

Methods
This was a prospective analysis of the International
Surgical Outcomes Study (ISOS) describing infection
by 30 days after elective surgery. Associations
between postoperative infection (primary outcome)
and baseline demographic, surgical, and anaesthetic
risk factors were assessed. Analyses were carried out
using logistic and linear regression models.
Secondary outcomes were 30-day mortality and
duration of hospital stay. Treatments received by
patients after di!erent types of infection were
:
 evaluated.

Results
Some 44 814 patients were included in the analysis,
with a total of 4032 infections occurring in 2927
patients (6.5 per cent). Overall, 206 patients died, of
whom 99 of 2927 (3.4 per cent) had infection. Some
737 of 4032 infections (18.3 per cent) were severe;
the most frequent types were superficial surgical-
site infection (1320, 32.7 per cent), pneumonia (708,
17.6 per cent), and urinary tract infection (681, 16.9
per cent). Excluding missing data, antimicrobials
were used in 2126 of 2749 infections (77.3 per cent),
and 522 of 2164 patients (24.1 per cent) required
admission to critical care. Factors associated with an
increased incidence of infection in adjusted analyses
were: age, male sex, ASA grade, co-morbid disease,
preoperative anaemia, anaesthetic technique,
surgical category, surgical severity, and cancer
surgery. Infection significantly increased the risk of
death (odds ratio 4.68, 95 per cent c.i. 3.39 to 6.47; P 
< 0.001), and duration of hospital stay by on average
6.45 (6.23 to 6.66) days (P < 0.001).

Conclusion
Infection is a common complication after elective
surgery. Recognition of modifiable risk factors will
help inform appropriate prevention strategies.

Resumen
Antecedentes
La infección postoperatoria es una de las
complicaciones más frecuentes e importantes tras la
:
 cirugía. La epidemiología de la infección después de
cirugía electiva no está bien descrita.
Métodos
Se llevó a cabo un análisis prospectivo del
International Surgical Outcomes Study (ISOS) que
describe la infección a los 30 días después de cirugía
electiva. Se evaluó la asociación entre infección
postoperatoria (resultado primario) y factores de
riesgos basales demográficos, quirúrgicos y
anestésicos. Los análisis se realizaron mediante
modelos de regresión logísticos y lineales. Los
resultados secundarios fueron mortalidad a los 30
días y duración de la estancia hospitalaria. Se
describen los tratamientos que recibieron los
pacientes tras diferentes tipos de infección. Los
resultados se presentan como n (%) o razón de
oportunidades (odds ratio, OR) con los i.c. del 95%.
Resultados
Se incluyeron 44.814 pacientes en el análisis con un
total de 4.032 infecciones que ocurrieron en 2.927
(6,5%) pacientes. Globalmente, 206 pacientes
fallecieron, de los cuales 99/2927 (3,4%) tenían
infección. Las infecciones fueron graves en
737/4.032 (18,3%) y los tipos más frecuentes fueron
superficiales del sitio quirúrgico 1.320/4.032
(32,7%), neumonía 708/4.032 (17,6%) y urinarias
681/4.032 (16,9%). Al excluir los datos perdidos, los
antibióticos se utilizaron en 2.126/2.749 (77,3%) de
las infecciones y 522/2.164 (24,1%) pacientes
requirieron ingreso en unidades de cuidados
intensivos. Los factores siguientes se asociaron con
un aumento en la incidencia de infección en los
análisis ajustados: edad, sexo masculino, grado ASA,
:
 comorbilidades, anemia preoperatoria, técnica
anestésica, categoría quirúrgica, gravedad de la
cirugía, y cirugía por cáncer. La infección aumentó
significativamente el riesgo de muerte (OR 4,68 (i.c.
del 95% 3,39-6,47); P < 0,001)) y duración de la
estancia hospitalaria en 6 días como promedio (i.c.
del 95% 6,23-6,66); P < 0,001)).
Conclusión
La infección es una complicación frecuente tras
cirugía electiva. La identificación de los factores
clave de riesgo que son modificables ayudará a
adoptar estrategias adecuadas de prevención.

Topic: anemia, care of intensive care unit patient,

urinary tract infections, pneumonia, preoperative care,
surgical procedures, elective, surgical procedures,
operative, surgical wound infection, infections,
anesthesia procedures, mortality, postoperative
infections, cancer surgery, surgical outcome,
prevention, missing data, primary outcome measure

Introduction

Postoperative complications place significant clinical and

1
economic burdens on healthcare . This results from
increased patient morbidity and mortality, prolonged
hospital stays and readmissions, as well as increased use
2–4
of resources including critical care . As developments in
healthcare systems increase access to surgical treatments
globally, the number of patients undergoing surgical
:
 procedures and subsequently su!er postoperative
5–7
complications is also increasing . Infection has been
shown to be the most frequently occurring complication,
developing in 10 per cent of patients undergoing surgical
procedures, with as many as 20 per cent of patients
4,8,9
having multiple infections .

There has been successful widespread implementation of

multimodal interventions, including clinical practice
guidelines, surgical safety checklists, and enhanced
10–12
recovery programmes . However, despite these
strategies, potentially avoidable infections continue to be
a problem. Causative factors for postoperative infection
remain unclear. In the case of development of surgical-
site infection, for example, it is hypothesized that
infection may not necessarily result from intraoperative
contamination but from pathogens from sites remote
13
from the operative wound . A number of patient-related
risk factors have been reported, including older age,
smoking, and co-morbid disease, although the findings
have not been replicated consistently between studies
across di!erent surgical categories and especially not at
4
an international level .

There have been strong recommendations against

extended duration of antibiotic therapy and increased
14–18
worldwide concerns about antimicrobial resistance .
Nevertheless, there remains a heavy reliance on the use of
antimicrobials both in prophylaxis and prolonged or
19,20
multiple courses of treatment . Consequently, new
treatment approaches are needed to prevent infection as
well as to better understand how patients develop
infectious complications after di!erent types of surgery
and the severity of harm which results, especially on a
:
 global level. There are few large data sets of complication
rates after surgery and even fewer focusing on infectious
complications. International comparative data might
provide important insights into delivery of healthcare for
surgical patients. The International Surgical Outcomes
4
Study (ISOS) aimed to provide a detailed description of
postoperative complications across a large international
cohort. The aim of the present study was to assess
perioperative risk factors and outcomes associated with
infection after a range of elective surgical procedures in
multiple countries.

Methods
4
This was a planned secondary study of ISOS , an
international multicentre cohort study of perioperative
morbidity and mortality in patients undergoing elective
surgery (ISRCTN51817007). Data were collected during a
7-day period between April and August 2014 in 474
hospitals in 27 countries. All patients admitted to
participating centres for elective surgery with a planned
overnight stay were eligible. Patients undergoing day-
case surgery or radiological procedures were excluded
because they followed a dedicated pathway of care.
Patients were followed up for a maximum of 30 days after
surgery.

Data collection
The data set for these analyses included all patients with
outcome data restricted to 30 days after surgery. Detailed
and standardized data were collected before surgery,
:
 during the hospital stay until discharge, and then at 30
days after surgery. Where an infection occurred,
additional data were collected. Independent variables
included in analyses were patient characteristics (age,
sex, smoking status, ASA status, co-morbid disease,
preoperative blood results); and anaesthetic and surgical
factors (type of anaesthetic, surgical category, severity of
surgery, laparoscopic surgery, cancer surgery, use of
surgical checklist). Full definitions of the variables
included in this analysis are documented on the ISOS
study website (http://www.isos.org.uk).

Outcome measures
The primary outcome measure was the development of
postoperative infection within 30 days after surgery. This
was a composite measure of six di!erent types of
infection, where more than one type can occur in the
same patient: superficial surgical site, deep surgical site,
body cavity, pneumonia, urinary tract, and bloodstream.
Each type was graded by severity (mild, moderate,
severe). Clinical diagnosis and grading of infection were
done using a pragmatic approach at individual sites.
Additional guidance definitions were provided in the ISOS
study protocol for use where the nature and severity of a
possible complication was uncertain
(http://www.isos.org.uk). Secondary outcome measures
were 30-day mortality and duration of hospital stay,
comparing patients who developed postoperative
infection and those who did not.

Statistical analysis
:
 A prospective statistical analysis plan was completed
before commencing any analyses (DOI:
21
10.17636/10165489) . Patients with data missing for
postoperative infection or mortality were excluded from
the analysis. Baseline characteristics are presented for all
patients and categorized by postoperative infection
status. Categorical data are reported as number with
percentage, normally distributed data as mean (s.d.), and
non-normally distributed data as median (i.q.r.).
Incidence of infection is presented by type and severity.
The primary outcome measure was analysed using
mixed-e!ects regression modelling with a random
intercept for country and site. Results of unadjusted and
adjusted (multivariable) analyses are presented. Adjusted
models included all baseline co-variables. For secondary
outcomes, results for each type of infection are shown.
Rates of di!erent treatments for postoperative infectious
complications by type of infection are also reported.
Results are presented as odds ratios (ORs) or β coe#cients
with 95 per cent confidence intervals and P values. All
®
analyses were performed using Stata version 15.1
(StataCorp, College Station, Texas, USA).

Results

Some 44 814 patients from the ISOS study cohort were

included in this analysis (Fig. 1). One patient did not have
infection status recorded at 30 days after operation, and
was included in descriptive summaries but excluded from
further outcomes analysis. There was a total of 4032
infection events occurring in 2927 patients (6.5 per cent);
680 patients (1.5 per cent) developed multiple infections.
:
 The most frequent types of infection were superficial
surgical-site infection (SSI), pneumonia, and urinary
tract infection; the majority of infections were classed as
mild or moderate.

Fig. 1

Study flow diagram

ISOS, International Surgical Outcomes Study.

:
 Patients who developed infections were older than
patients who did not, and a greater proportion were men
or classed as ASA III or IV. Patients with infection had an
increased prevalence of all types of co-morbid disease and
low preoperative haemoglobin levels compared with those
without infection (Table 1). Overall, the surgical
procedures were most commonly carried out under
orthopaedic, head and neck, and obstetrics and
gynaecology specialties. In the infected group, patients
had orthopaedic, lower gastrointestinal, and urology and
kidney procedures most frequently (Table 1). Proportions
of patients with infection in relation to surgical specialty
are shown in Fig. 2.

Fig. 2

Proportion of patients developing infection by surgical category

a Presence of infection and b type of infection. GI, gastrointestinal;

SSI, superficial surgical-site infection; DSI, deep superficial surgical-
site infection; UTI, urinary tract infection.

Table 1 Baseline characteristics categorized by infection status

:
 All patients
(n = 44 814)*

Age (years) (n = 44 799)

 Mean(s.d.) 55.4(17.1)

 Median (i.q.r.) 57 (43–69)

Men 20 458 of 44 809 (45.7)

Current smoker 7913 of 44 565 (17.8)

ASA fitness grade (n = 44 723)

 I 11 227 (25.1)

 II 22 265 (49.8)

 III 10 193 (22.8)

 IV 1038 (2.3)

Co-morbid disease

 Coronary artery disease 4588 of 44 707 (10.3)

 Heart failure 1882 of 44 707 (4.2)

 Diabetes mellitus 5171 of 44 712 (11.6)

 Cirrhosis 342 of 44 707 (0.8)

 Metastatic cancer 1706 of 44707 (3.8)

 Stroke 1492 of 44 707 (3.3)

 COPD or asthma 4094 of 44 707 (9.2)

 Other 18 607 44 707 (41.6)

Preoperative blood results*

:
  Haemoglobin (g/l)) 13.2 (12.0–14.3)

(n = 38 794 )

9
 Leucocytes (× 10 /l) 6.9 (5.6–8.7)

(n = 37 196)

 Sodium (mmol/l) 140 (138–142)

(n = 35 630)

 Creatinine (µmol/l) 71 (60–87)

(n = 36 516)

Anaesthetic technique

 General 34 152 of 44 779 (76.3)

 Spinal 7600 of 44 779 (17.0)

 Epidural 2943 of 44 779 (6.6)

 Sedation/local 4918 of 44 279 (11.1)

Surgical procedure (n = 44 805)

 Orthopaedic 9459 (21.1)

 Breast 1538 (3.4)

 Obstetrics and gynaecology 5674 (12.7)

 Urology and kidney 4871 (10.9)

 Upper gastrointestinal 1986 (4.4)

 Lower gastrointestinal 3073 (6.9)

 Hepatobiliary 2282 (5.1)

 Vascular 1599 (3.6)

:
  Head and neck 6510 (14.5)

 Plastics and cutaneous 1670 (3.7)

 Cardiac 1716 (3.8)

 Thoracic 1157 (2.6)

 Other 3270 (7.3)

Severity of surgery (n = 44 789)

 Minor 8411 (18.8)

 Intermediate 20 203 (45.1)

 Major 16 175 (36.1)

Other measures

 Laparoscopic surgery 7087 of 44 799 (15.8)

 Cancer surgery 9006 of 44 297 (20.3)

 Use of surgical checklist 40 245 of 44 783 (89.9)

 Critical care immediately a#er surgery 4360 of 44 295 (9.8)

Values in parentheses are percentages unless indicated otherwise;

*values are median (i.q.r.). *Infection data missing for one patient.
COPD, chronic obstructive pulmonary disease.

Results of multivariable analysis are shown in Table 2. The

risk of postoperative infection increased with older age,
even after adjustment for ASA grade and co-morbid
disease. Risk of postoperative infection increased with
increasing ASA grade. Co-morbid diseases that remained
significantly associated with increased risk were heart
failure (adjusted OR 1.25, 95 per cent c.i. 1.04 to 1.49; P = 
:
 0.016), metastatic cancer (adjusted OR 1.32, 1.09 to 1.60; P 
= 0.004), and COPD or asthma (adjusted OR 1.33, 1.16 to
1.53; P < 0.001). Preoperative anaemia (haemoglobin below
9
10 g/l), raised leucocyte count (at least 11 × 10 /l),
hyponatraemia (sodium concentration less than 135
mmol/l), and low creatinine level (below 45 µmol/l) were
all associated with increased risk of infection after
surgery (all P < 0.001). Use of general anaesthesia and
epidural techniques was also greater in patients who
developed infection. Increasing severity of surgery
increased the risk of postoperative infection, as did cancer
surgery, and use of laparoscopy reduced the risk of
infection by 35 per cent (OR 0.65, 0.56 to 0.76; P < 0.001).
The majority of surgical procedures documented use of a
surgical checklist (89.9 per cent), but this was not
associated with postoperative infection in unadjusted or
adjusted analyses.

Table 2 Risk factors associated with postoperative infection

*
Infection Unadjusted analysis

†
Odds ratio

Age (years)

 < 50 665 (4.1) 1.00 (reference)

 ≥ 50–70 1286 (7.1) 1.87 (1.69, 2.07)

 ≥ 70 974 (9.3) 2.68 (2.41, 2.99)

Male sex 1318 (5.4) 1.48 (1.37, 1.60)

Current smoker 528 (6.7) 1.01 (0.91, 1.11)

:
 ASA fitness grade

 I 361 (3.2) 1.00 (reference)

 II 1240 (5.6) 2.24 (1.97, 2.55)

 III 1131 (11.1) 5.47 (4.77, 6.28)

 IV 190 (18.3) 12.99 (10.46, 16.14)

Comorbid disease

 Coronary artery disease 502 (10.9) 1.98 (1.77, 2.21)

 Heart failure 265 (14.1) 2.44 (2.10, 2.82)

 Diabetes mellitus 509 (9.8) 1.70 (1.52, 1.88)

 Cirrhosis 55 (16.1) 2.34 (1.70, 3.22)

 Metastatic cancer 226 (13.3) 2.24 (1.91, 2.61)

 Stroke 163 (10.9) 1.71 (1.44, 2.04)

 COPD or asthma 388 (9.5) 1.66 (1.48, 1.87)

 Other 1570 (8.4) 1.67 (1.53, 1.81)

Haemoglobin (g/l)

 <10 394 (15.0) 2.02 (1.78, 2.31)

 ≥ 10–13 1147 (8.0) 1.00 (reference)

 ≥ 13 1164 (5.3) 0.64 (0.58, 0.70)

9
Leucocytes (×10 /l)

 < 4 104 (6.4) 1.03 (0.83, 1.27)

 ≥ 4–11 2071 (6.5) 1.00 (reference)

 ≥ 11 454 (12.1) 1.94 (1.73, 2.18)

:
 Sodium (mmol/l)

 < 135 277 (13.4) 1.96 (1.70, 2.27)

 ≥ 135–145 2235 (7.0) 1.00 (reference)

 ≥ 145 122 (7.6) 1.06 (0.86, 1.30)

Creatinine (µmol/l)

 < 45 147 (7.9) 1.33 (1.10, 1.59)

 ≥ 45–110 2086 (6.7) 1.00 (reference)

 ≥ 110 399 (11.5) 1.75 (1.55, 1.97)

Anaesthetic technique

 General 2403 (7.0) 1.56 (1.40, 1.73)

 Spinal 440 (5.8) 0.83 (0.73, 0.93)

 Epidural 322 (10.9) 2.18 (1.91, 2.49)

 Sedation/local 195 (4.0) 0.56 (0.48, 0.66)

Surgical procedure

 Orthopaedics 612 (6.5) 1.00 (reference)

 Breast 61 (4.0) 0.59 (0.45, 0.78)

 Obstetrics and gynaecology 190 (3.4) 0.48 (0.40, 0.57)

 Urology and kidney 300 (6.2) 0.94 (0.81, 1.10)

 Upper gastrointestinal 218 (11.0) 1.95 (1.64, 2.33)

 Lower gastrointestinal 345 (11.2) 2.01 (1.73, 2.34)

 Hepatobiliary 161 (7.1) 1.11 (0.92, 1.35)

:
  Vascular 152 (9.5) 1.59 (1.30, 1.94)

 Head and neck 227 (3.5) 0.47 (0.40, 0.56)

 Plastics and cutaneous 142 (8.5) 1.27 (1.04, 1.56)

 Cardiac 263 (15.3) 2.88 (2.42, 3.42)

 Thoracic 114 (9.9) 1.71 (1.37, 2.15)

 Other 142 (4.3) 0.67 (0.55, 0.82)

Severity of surgery

 Minor 346 (4.1) 1.00 (reference)

 Intermediate 1002 (5.0) 1.41 (1.24, 1.62)

 Major 1576 (9.7) 3.61 (3.16, 4.13)

Other measures

 Laparoscopic surgery 350 (4.9) 0.72 (0.64, 0.81)

 Cancer surgery 824 (9.2) 1.75 (1.60, 1.91)

 Use of surgical checklist 2614 (6.5) 1.11 (0.91, 1.35)

Values in parentheses are

*percentages and

†
95 per cent confidence intervals.

‡
Based on 32 890 observations. COPD, chronic obstructive
pulmonary disease. Unadjusted and adjusted (multivariable) logistic
regression models for development of postoperative infection were
used, including random e$ects to control for country and centre.
:
 Comparing di!erent types of postoperative infection,
patients with pneumonia and urinary tract infections
were older (median age 66.0 years for both) compared
with other types (median age 59.0–63.0 years). A higher
proportion of patients who developed pneumonia had a
history of coronary artery disease, stroke, and COPD or
asthma. SSI occurred most frequently after orthopaedic
surgery (25.0 per cent), pneumonia after cardiac
procedures (19.2 per cent), and urinary tract infections
after urology and kidney surgery (27.6 per cent) (Table
S1).

Among patients with known infection status, there were

206 deaths overall (0.5 per cent). A higher proportion of
patients with infection died than those without. Patients
who died had more severe infections (Table S2).
Associations between postoperative infection and
secondary outcomes are shown in Tables S3 and S4.
Development of any type of infection increased risk of
death within 30 days of surgery by 4.68 (95 per cent c.i.
3.39 to 6.47) times (P < 0.001). The risk of death was
highest after bloodstream, body cavity, and deep
surgical-site infections. However, event rates were low
ranging from 1.3 per cent following SSI to 11.5 per cent
after bloodstream infections, resulting in wide confidence
intervals for estimates (Table S3). Patients who developed
infection spent 6.45 (6.23 to 6.66) days longer in hospital
after surgery than those who did not (P < 0.001). This
ranged from 5.93 (5.50 to 6.35) days after urinary tract
infection (P < 0.001) to 9.43 (8.88 to 9.99) days after body
cavity infection (P < 0.001) (Table S4).

Types of treatment for infective complications were

assessed after excluding patients who required the same
:
 types of treatment for other non-infective postoperative
complications (Table 3). Of patients who developed
postoperative infection, 77.3 per cent received drug
therapy, blood transfusion or parenteral nutrition; 31.3
per cent required a surgical or radiological procedure; and
24.1 per cent required critical care admission. Over half of
patients who developed a deep surgical-site or body
cavity infection had further surgical or radiological
intervention. Patients who developed pneumonia had the
highest rates of critical care admission.

Table 3 Treatments received for postoperative infections

n Drug therapy, blood transfusion or parenteral nutritio

No infection 41 886 2782 of 39 960 (7.0)

Infection 2927 2126 of 2749 (77.3)

Infection type

 Superficial surgical site 1320 854 of 1245 (68.6)

 Deep surgical site 566 442 of 536 (82.5)

 Body cavity 340 276 of 324 (85.2)

 Pneumonia 708 602 of 659 (91.4)

 Urinary tract 681 501 of 626 (80.0)

 Bloodstream 417 349 of 394 (88.6)

Values in parentheses are percentages. The denominator in each

column is the number of patients; these vary according to rates of
missing data. Treatment a#er development of postoperative
infection for each type and total number of infections is shown. Only
patients who did not develop non-infective complications are
:
 included.

Discussion

The principal finding of this analysis was that infection

occurred in one in 15 patients, and patients with infection
were 4.68 times more likely to die after elective surgery.
This study has provided detailed outcomes data on
postoperative infection in a population of more than 44
000 patients undergoing elective inpatient surgery in 27
low-, middle-, and high-income countries worldwide.
9
Compared with a mixed surgical cohort , elective surgery
resulted in lower rates of infection and also lower
mortality rate among patients with infection. This may
reflect a di!erent patient population undergoing urgent
or emergency surgical treatment. In the present analysis,
nearly one in five infections were severe and nearly one-
quarter resulted in critical care admission, most
frequently for patients who developed pneumonia. This
suggests that infection remains a significant
postoperative risk even after elective surgery. Drug
therapy was a mainstay of treatment for infective
complications, indicating that multiple courses of
antibiotics would probably have been used. Considering
the adverse e!ects of antimicrobial resistance, infection
prevention measures remain of key importance, and
understanding risk profiles and underlying mechanisms
20
underpins this .

Infections were identified as the most common

complications shown by baseline infection rates in the
4
ISOS study report . The present secondary analysis builds
:
 on this by presenting a more detailed, extended analysis
of associations with risk factors, treatments received, and
e!ects on clinical outcomes. Similar to results from
7,9,22
previous studies and within higher-acuity surgery ,
the most frequent infections following elective surgery
were SSI, pneumonia, and urinary tract infection.
Di!erent surgical procedures can result in a range of
di!erent types of infection, reinforcing the hypothesis
13
that di!erent mechanisms may be involved . Among
elective procedures, infection a!ects orthopaedic surgery
most frequently, compared with general surgery among
9
emergency operations . Orthopaedic surgery contributes
to the bulk of the elective surgical workload. As increasing
numbers of elective procedures are undertaken in patients
particularly with increasing age and co-morbid disease, it
is likely that higher rates of infection, and related
23
morbidity and mortality will result .

This analysis confirmed in a large international cohort the

association between infection and previously reported
risk factors for postoperative morbidity, such as older
age, male sex, and higher burden of co-morbid
9,24–26
disease . Smoking was not shown to be associated
with infection, but this may be because of a lower
proportion of patients classified as being a current
smoker compared to an ever smoker; it was not possible
to assess previous smoking history. In adjusted analyses,
heart failure, metastatic cancer, and COPD or asthma were
consistently associated with increased risk of infection.
These conditions are known to impair postoperative
recovery, increase immunosuppression, and predispose to
27–29 9
pneumonia . Similar to findings in the VISION cohort,
associations with diabetes or coronary artery disease were
not shown.This may reflect that fact that severity of
:
 illness and other measures such as poor glucose control
30
have more impact than the diagnosis itself . There was
no association with use of a surgical checklist, which
suggests that other factors related to underlying
pathophysiology may contribute more to risk of infection.

Preoperative anaemia increased the risk of postoperative

infection by over 50 per cent. A number of studies have
shown that anaemia is associated with postoperative
31,32
complications across di!erent surgical specialties .
The prevalence of anaemia has been reported to be up to
90 per cent in the surgical population secondary to
multiple causes, including cancer or chronic
33
inflammation . Anaemia may reflect increased baseline
risk or be involved mechanistically in the development of
34,35
infection . These findings reinforce the need for
perioperative interventions, such as patient blood
36
management in timely detection and management .

Infection rates were significantly higher after surgical

procedures undertaken using a general anaesthetic or
37,38
epidural technique. Other studies comparing neuraxial
with general anaesthetic techniques in lower limb
orthopaedic procedures and caesarean sections have
shown associations with improved postoperative
outcomes. However, multiple factors influence primary
anaesthetic technique, and direct comparisons cannot be
made using observational data alone. The availability of
neuraxial anaesthesia may vary; sole neuraxial techniques
may be associated with lower rates of infection owing to a
low risk from the surgical procedure or shorter duration
of surgery. Infection risk from general anaesthesia with
and without the use of epidurals may be related to
associated procedures such as intubation and mechanical
:
 ventilation.

There are few large data sets of rates of postoperative

infection, the most frequently occurring surgical
complication. This study was a planned secondary
analysis of a prospective cohort study. Although data
collection was completed in 2014, this cohort remains one
of the largest and representative data sets in elective
surgery. During the past few years, clinical practice
targeting infectious complications has changed only
marginally and few new or significant interventions have
been put into place. Strengths of the study include
analysis of international data covering large varied
populations, making the findings broadly generalizable to
patients having elective surgery. Comparing elective
procedures reduces confounding by risk factors related to
higher-acuity surgery and emergency surgical
presentations. A prespecified approach with an a priori
statistical analysis plan was used and there was a low rate
of missing data. Limitations include limited causal
interpretations because of the observational design. There
are also additional variables that were not available for
inclusion in this analysis, such as BMI, aggregated
measures of the burden of co-morbid disease, measures
of frailty, and socioeconomic status. Di!erences between
commonly used grading systems are more pronounced in
low‐ and middle‐income countries as treatment-based
classifications may introduce bias when there are
di!ering levels of resources and lower availability of
39
specific treatments . As a result, there may have been
some heterogeneity in definition and severity grading of
infection; however, the overall sample size and uniform
guidance for data collection are likely to have minimized
these e!ects. Outcome data were collected to 30 days after
:
 operation; longer-term follow-up would have allowed
analysis of readmission rates and elucidation of
mechanisms more strongly associated with delayed
complications and late deaths.

Conclusions

This analysis of an international cohort indicate that large

numbers of patients develop infective complications after
elective in-patient surgery globally and provide detailed
estimates of risk factors and outcomes. Improving access
to surgical treatment and increasing surgical volumes
should take into account associated risks of infection and
subsequent high demand on peri-operative services.
Prevention strategies are crucial in reducing these risks
and in the prevention of antimicrobial resistance.

Acknowledgements

R.M.P. holds research grants, and has given lectures

and/or performed consultancy work for Nestle Health
Sciences, GlaxoSmithKline, Intersurgical, and Edwards
Lifesciences, and is a member of the Associate Editorial
Board of the British Journal of Anaesthesia.

Disclosure. The authors declare no other conflict of

interest.

Supplementary material
Supplementary material is available at BJS online.
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Author notes

Members of the International Surgical Outcomes Study (ISOS) Group

are collaborators in this study and are listed in Appendix S1

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Supplementary data

znaa075_Supplementary_Data - zip file

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