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Original Article

Protocol for Developing a Surveillance System for Surgical Site

Infections
Purva Mathur, Samarth Mittal1, Vivek Trikha1, Ayush Lohiya, Surbhi Khurana, Sonal Katyal, Nidhi Bhardwaj, Sushma Sagar2, Subodh Kumar2,
Rajesh Malhotra1, Kamini Walia3
Departments of Laboratory Medicine and 1Orthopedics, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences,
2
Division of Trauma Surgery, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, 3Epidemiology and Communicable Diseases,
Indian Council of Medical Research, New Delhi, India

Abstract
Purpose: Healthcare-associated infections (HCAIs/ HAIs) are the most common adverse occurrences during health care delivery. Across the
globe, millions of patients are affected by HAIs annually, with a higher burden and impact in developing nations. a major lacuna in planning
preventing protocols is the absence of National Surveillance Systems in most low-middle income countries, which also prevents allocation
of resources to the high-priority areas. Among all the HAIs, there is a huge global burden of SSIs, in terms of morbidity, prolonged hospital
stays, increased antimicrobial treatment as well as attributable mortality. Method: This manuscript details the process of establishment of an
SSI surveillance protocol at a level-1 trauma centre in North India. Result and Conclusion: Surveillance is an essential tool to reduce this
burden. It is also an important primary step in recognizing problems and priorities, and it plays a crucial role in identifying risk factors for SSI
and to be able to target modifiable risk factors. Therefore, it is imperative to establish reliable systems for surveillance of HAIs, to regularly
estimate the actual burden of HAIs, and to use these data for developing indigenous preventive measures, tailored to the country’s priorities.

Keywords: Healthcare‑associated infections, India, surgical site infections, surveillance

Introduction to 17.8%, depending primarily on the type of surgeries. A WHO

Healthcare‑associated infections  (HCAIs/HAIs) are the most
frequent adverse events during health‑care delivery. Millions
of patients are affected by HAIs every year worldwide; the
burden and impact of these infections being greater in low‑ and
middle‑income countries  (LMICs). Hospital‑wide prevalence
of HAI varies from 5.7% to 19.1%, with a pooled prevalence of
10.1%. Among the HAIs, surgical site infections (SSIs) are one
of the most common, morbid and costly to treat. Worldwide,
approximately 187–281 million surgical procedures are performed
each year. SSIs are one of the undesirable and serious outcomes of
surgeries; despite the high burden, most SSIs are preventable.[1‑8]
The global burden of SSIs is huge, in terms of morbidity,
repeat surgeries, prolonged hospitalisation, increased length of
antimicrobial treatment and attributable mortality (0.4%–0.8% of
SSIs resulting in death). Large‑scale studies done in the developed
countries as part of national surveillance systems or networks or
multi‑hospital surveys have reported SSI rates varying from 0.9%
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survey found that in LMICs, the incidence of SSI ranged from
1.2 to 23.6/100 surgical procedures. This contrasted with rates
between 1.2% and 5.2% in high‑income countries. Table 1 gives
a brief overview of the SSI rates in developed nations.[4,9‑15]
Burden of Surgical Site Infections in Low‑ and
Middle‑Income Countries
The burden of SSIs in these countries is much higher than the
Address for correspondence: Dr. Purva Mathur,
Department of Laboratory Medicine, Jai Prakash Narayan Apex Trauma
Centre, All India Institute of Medical Sciences, New Delhi ‑ 110 029, India.
E‑mail: purvamathur@yahoo.co.in
Received : 21‑11‑2019 Revised : 29-11-2019
Accepted : 03-12-2019 Published Online : 29-01-2020
This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
is given and the new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com

DOI: How to cite this article: Mathur P, Mittal S, Trikha V, Lohiya A, Khurana S,
10.4103/ijmm.IJMM_19_446 Katyal S, et al. Protocol for developing a surveillance system for surgical
site infections. Indian J Med Microbiol 2019;37:318-25.

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Mathur, et al.: SOP for SSI
Table 1: Burden of surgical site infections in developed nations
Country and year Type of surveillance network/
of study number of hospitals
USA, 2014[10‑11] NHSN
3654 hospitals
European countries, European CDC
2010-2011[12‑13]
Australia, 2002-2013[14] National HAI surveillance network
Japan, 2013[4,15] National Nosocomial Infection
Surveillance system
Singapore, 2008 Tertiary care hospital study
SSI: Surgical site infection, NHSN: National Healthcare Safety Network, CDC: Centers for Disease Control and Prevention, HAI: Healthcare‑associated
infection, LOS: Length of stay, GI: Gastro-intestinal
developed countries. In the 2011 WHO report on the global
burden of HAI from LMICs, SSI was the most frequent
HAIs reported hospital‑wide, with the level of risk being
much higher than in developed countries. In this report, the
pooled SSI incidence in LMICs and developed countries
were, respectively, 11.8 and 5.6/100 surgical procedures.
The rates of SSIs have ranged from 2.1 in the Republic of
Korea to 2.5%–15.4% in Uruguay, and 1.9%–3.1% in Chile.
The overall prevalence of SSI in Africa/Middle East, Latin
America, Asia and China was reported to be 10%, 7%, 4%
and 4%, respectively. In a review published in 2019 by Couto
et al., the overall prevalence of SSI in developing countries in
elective clean and clean‑contaminated surgeries was estimated
to be 6%, increasing to 15% when studies only focusing on
post‑discharge surveillance were included.[4,10‑16]
Surveillance for Surgical Site Infections
In most countries, the burden of HAIs is grossly underestimated
for want of proper surveillance and reporting systems.
Estimation of the national burden of HAIs is a prerequisite
for planning infection control policies. Robust evidence
emphasises the fact that HAI can be prevented, and the burden
is reduced by as much as 50%.[17‑20]
Surveillance is defined as “the ongoing, systematic collection,
analysis and interpretation of health data essential to the planning,
implementation and evaluation of public health practice, closely
integrated with the timely dissemination of these data to those
who need to know.” Surveillance of SSI is part of the WHO safe
surgery guidelines. Many countries have introduced mandatory
surveillance of SSI, such as the UK and certain states in the USA,
whereas other countries have voluntary‑based surveillance, such
as France, Germany and Switzerland.[21‑36]
There is a lack of national surveillance systems in most LMIC,
which is a major lacuna in planning preventing protocols and
allocating resources to the highpriority areas. Therefore, there
is an urgent need:
• To establish reliable systems for HAI surveillance
• To gather data on the actual burden of HAIs regularly
• To use this data for developing indigenous preventive
measures, tailored to the country’s priorities.
Indian Journal of Medical Microbiology  ¦  Volume 37  ¦  Issue 3  ¦  July-September 2019
Rate of Estimated additional cost of treatment/other
SSI (%) implications due to SSI in the country
0.86 US $3.5 billion-10 billion
Additional LOS 9.7 days per SSI
0.75-9.5 1.4-19.1 billion euros
Additional LOS 6.5 days, with three times increased
cost of treatment of infected patients
2.8
15 (GI Additional $8791 per SSI case. Additional LOS
surgery) 20.7 days, may extend to 48.9 days in cardiac surgeries
8.3
Evaluation of the key determinants of SSIs (or risk factors) is
also an essential step to identify strategies and measures for
improvement.
Surveillance of SSIs is very different from other HAIs such as
ventilator‑associated pneumonia (VAP), central line‑associated
bloodstream infections  (CLABSIs) and catheter‑associated
urinary tract infections (CAUTIs). The primary difference being
that surveillance for VAP, CLABSI and CAUTI are truncated at
the time of discharge from the unit/hospital. In contrast, most
SSIs develop after the patient is discharged from the hospital,
considering the ever‑shortening in‑hospital stay after surgeries.
Some SSIs may develop as long as 3 months or even a year after
the surgery. SSI surveillance, therefore, requires a very prolonged
follow‑up, a lot more engagement by the patients and health‑care
workers, and therefore, not feasible in many LMICs.[17‑19,37,38]
Surveillance is an essential tool to reduce its burden. It is also
an important first step in identifying problems and priorities;
and it plays an important role in recognising risk factors for
SSI thus, helping to target modifiable risk factors.
Carefully obtained surveillance data can identify needed
infection prevention and control (IPC) interventions and areas
of opportunity for improvements in care. The surveillance data
can also help assess the quality of infection prevention efforts.
Both process measures (for example, the implementation of
preventive measures) and outcome measures (SSI rates) should
be measured through surveillance so that IPC measures can be
implemented, and performance improved. The application of
standardised definitions is one of the minimum requirements
for data comparisons at local, national and international levels.
The use of standardised definitions is crucial to the reliability
of SSI surveillance for the following reasons:
• It allows establishing that the infection was acquired
during the hospital stay
• To ensure that it is a true infection and not colonisation
• Allows for inter‑hospital comparisons and benchmarking.
The National Healthcare Safety Network (NHSN) provides the
most reliable and updated definitions.[1,39,40] At the All India Institute
of Medical Sciences, New Delhi, we have initiated a multi‑centric
study, supported by ICMR, where 90‑day post‑discharge
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Mathur, et al.: SOP for SSI

surveillance is being conducted to ascertain the actual prevalence Outcome measures

of SSI in a select group of surgeries. This manuscript describes
the process of the establishment of an SSI surveillance protocol.
Objectives of a surveillance program
• Collection of data on SSI rates to ascertain the magnitude
of the problem
• Analysis of the data to identify and investigate trends
• Ascertain the most common pathogens and their
susceptibility patterns
• Identify the risk factors in the Indian set‑up
• Interpretation of analysed data at regular intervals to
provide feedback
• Data‑driven improvement actions
• Evaluation of preventive interventions
• The following are the essential prerequisites for
developing a surveillance system for SSIs[1,41-43]
• An standard operating procedure (SOP) with objectives,
methodology and all elements of the surveillance process
• Adequate human resources for surveillance  (infection
control nurses and epidemiologists)
• Training of all surveillance staff (induction and at regular
intervals)
• Consistent application of definitions and common
methodology
• IT/Informatic services (to design an interpret reports)
• Data quality/evaluation methods
• Development of a feedback mechanism
• Use surveillance findings in developing/implementing
preventive activities
• Each hospital to use its data for internal benchmarking
and setting targets.
The SSI surveillance programme should measure both
infection rates and compliance rates with surgical infection
prevention processes.
Process and Outcome Measures
SSI surveillance should include measures of processes to
indicate whether caregivers are adhering to best practices and
established policies as well as the outcomes of care during
the pre‑operative, intra‑operative and post‑operative phases.
Process measures
In the pre‑operative phase, hand hygiene, accurate assessment
of patient status and risk factors, and initiating specific
procedures such as maintaining normothermia, are some of
the IPC processes. In the intra‑operative stage, IPC processes
include skin antisepsis, maintaining normothermia and glucose
monitoring. Postoperatively, aseptic wound care is a primary
prevention process.[44‑49]
Calculation of compliance
All calculations can be performed by using the formula of:
The number of events (numerator) divided by the number of
persons at risk or number of expected processes.
Monitoring/surveillance for surgical site infection
For surveillance purposes, SSIs are divided into categories
involving only skin and subcutaneous tissue  (superficial
incisional SSIs), those involving deeper soft tissues of the
incision (deep incisional SSIs), and those involving any part
of the deep anatomy (organ space SSIs), such as a joint space.
The definitions for SSIs have been adopted from the Centres
for Disease Control and Prevention NHSN system.[50‑52] Table 2
details the classification of SSI.
We have developed a website for SSI surveillance, where
the SOP is available. Definitions of SSI surveillance, wound
classification and the details of surveillance methodology
can be accessed at http://ssi.haisindia.com. Figure 1 shows a
screenshot of the home page of the website.
Case finding
This requires active, patient‑based, prospective surveillance.
Both in‑hospital and post‑discharge surveillance methods
should be used to detect SSIs. Review methods may include
one or more of the following:[50‑52]
• Direct inspection of the wound
• Medical records/surgical/OT notes/physician’s notes/
admission, readmission, ED notes
• Laboratory/X‑ray, other diagnostic test reports
• Information from the patients and families
• Surveys by mail or telephone.
Role of the  Hospital Infection Control Nurses (HICNs)
(HICNs)/infection preventionists/epidemiologist/information
technology departments (if available)
• To lead the development of the SSI surveillance plan
• To perform the surveillance using established, approved,
and consistent surveillance criteria or definitions
• Analyse and present the data to all stakeholders.
Data collection
Collect SSI  (numerator) and operative procedure category
(denominator) data on all procedures included in the selected
procedure categories for at least 1  month. The numerator
and denominator data forms are available on the website
Figure 1: Home page of surgical site infection web page

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Mathur, et al.: SOP for SSI

Table 2: Classification of surgical site infections

Superficial incisional SSI
This is based on the following criteria:
DOE for infection occurs within 30 days after a surgical procedure (where day 1 = the procedure date) and involves only skin and subcutaneous tissue of
the incision and patient has at least one of the followings:
a. Purulent drainage from the superficial incision
b. Organisms identified from an aseptically‑obtained specimen from the superficial incision or subcutaneous tissue by a culture
c. Superficial incision that is deliberately opened by a surgeon and patient has at least one of the following signs or symptoms: Pain or tenderness;
localised swelling; erythema or heat
d. Diagnosis of a superficial incisional SSI by the surgeon/attending physician
There are two specific types of superficial incisional SSIs:
1. SIP ‑ A superficial incisional SSI that is identified in the primary incision in a patient that has had an operation with one or more incisions
2. SIS ‑ A superficial incisional SSI that is identified in the secondary incision in a patient that has had an operation with more than one incision
Deep incisional SSI
This is based on the following criteria:
The DOE for infection occurs within 30 or 90 days after the operative procedure (where day 1 = the procedure date) and
Involves deep soft tissues of the incision (for example, fascial and muscle layers) and patient has at least one of the following:
a. Purulent drainage from the deep incision
b. A deep incision that spontaneously dehisces, or is deliberately opened/aspirated by a surgeon/attending physician and organism is identified by
culture and patient has at least one of the following signs or symptoms: Fever (>38°C); localised pain or tenderness. A culture‑based test that has a
negative finding does not meet this criterion
There are two specific types of deep incisional SSIs:
1. DIP ‑ A deep incisional SSI that is identified in a primary incision in a patient that has had an operation with one or more incisions
2. DIS ‑ A deep incisional SSI that is identified in the secondary incision in a patient that has had an operation with more than one incision
Organ/space SSI
This is based on the following criteria:
DOE for infection occurs within 30 or 90 days after the operative procedure and infection involves any part of the body deeper than the fascial/muscle
layers, that is opened or manipulated during the operative procedure and patient has at least one of the following:
a. Purulent drainage from a drain that is placed into the organ/space
b. Organisms are identified from fluid or tissue in the organ/space by a culture‑based test
SSIs: Surgical site infections, SIP: Superficial incisional primary, SIS: Superficial incisional secondary, DIP: Deep incisional primary, DIS: Deep incisional
secondary, DOE: Date of event

http://ssi.haisindia.com. The surgical procedure must meet
the definition of an operative procedure to be included
in the surveillance. All procedures should be followed
for superficial, deep and organ/space SSIs. All patients
undergoing the defined surgeries (for which a hospital intends
to undertake SSI surveillance) need to be monitored for SSI.
SSI form should be completed for each SSI. The SSI form
includes patient demographic information and information
about the operative procedure, including the date and type
of procedure. Information about the SSI includes the date of
SSI, specific criteria met for identifying the SSI when/how
the SSI was detected, whether the patient developed a
secondary bloodstream infection, whether the patient died,
the organism(s) identified and the organisms’ antimicrobial
susceptibilities.[50‑52]
Calculation of Surgical Site Infection Rates
The most common outcome indicator is the SSI rate. For any
given period, denominator data represent the total number of
procedures within each category. Numerator data will be the
number of SSIs in that same period. SSI rates per 100 operative
procedures are calculated by dividing the number of SSIs by
the number of specific operative procedures and multiplying
the results by 100. SSIs should be included in the numerator
of a rate based on the date of procedure, not the date of the
event.[50‑52] Figures  2 and 3 show the SSI surveillance case
report form and denominator form, respectively. The forms
can be accessed at the website http://ssi.haisindia.com.
Additional terms
1. Date of event (DOE): For an SSI, the DOE is the date when
the first element used to meet the SSI infection criterion
occurs for the first time during the SSI surveillance
period. The date of the event must fall within the SSI
surveillance period to meet SSI criteria. The type of
SSI (superficial incisional, deep incisional or organ/space)
reported should reflect the deepest tissue layer involved
in the infection during the surveillance period. The date
of the event should be the date that the patient met the
criteria for the deepest level of infection
2. Duration of operative procedure: The interval in hours
and minutes between the procedure/surgery start time
(PST), and the procedure/surgery finish  (PF) time, as
defined by the Association of Anaesthesia Clinical
Directors
• PST: Time when the procedure is begun (e.g., incision for
a surgical procedure)
• PF: Time, when all instrument and sponge counts are
completed and verified as correct, all post‑operative
radiologic studies to be done in the  Operating room

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Mathur, et al.: SOP for SSI

Figure 2: Surgical site infection surveillance case report form (Complete form can be accessed at http://ssi.haisindia.com)

(OR), are completed, all dressings and drains are
secured, and the physicians/surgeons have completed all
procedure‑related activities on the patient
3. Emergency operative procedure: A  procedure that
is documented as per the hospital’s protocol to be an
emergency or urgent procedure
4. Inpatient operative procedure: An operative procedure
performed on a patient whose date of admission to
the Healthcare facility (HCF), and the date of discharge
are different calendar days
5. Outpatient operative procedure: An operative procedure
performed on a patient whose date of admission to the
HCF, and date of discharge are the same calendar day
6. Non‑primary Closure: Closure of the surgical wound
in a way which leaves the skin level completely open
following the surgery. Closure of any portion of the
skin represents primary closure. For surgeries with
non‑primary closure, the deep tissue layers may be closed
by some means (with the skin level left open), or the deep
and superficial layers may both be left completely open.
Wounds with non‑primary closure may or may not be
described as ‘packed’ with gauze or other material, and

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Mathur, et al.: SOP for SSI

Figure 3: Surgical site infection surveillance denominator form (Complete form can be accessed at http://ssi.haisindia.com)

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