The burden of aerobic bacterial nosocomial infections, associated risk factors and antibiotic susceptibility patterns in a surgical site in Ethiopia: A systematic review

Nosocomial Infection (NI) is an infection that acquired after the admission of patients to a hospital within 48-72 hrs, but not present during admission[1,2]. It is a major public health problem that causes morbidity, mortality and increased health care cost for hospitalization worldwide and remains signifi cant now a day’s [3,4]. Surgical Site Infections (SSI) are among these nosocomial an infection that occurs after an operation in the part of the body where the surgery took place. Most SSIs only involves the skin surrounding the incision; others may be deeper and more serious [5].


Introduction
Nosocomial Infection (NI) is an infection that acquired after the admission of patients to a hospital within 48-72 hrs, but not present during admission [1,2]. It is a major public health problem that causes morbidity, mortality and increased health care cost for hospitalization worldwide and remains signifi cant now a day's [3,4]. Surgical Site Infections (SSI) are among these nosocomial an infection that occurs after an operation in the part of the body where the surgery took place. Most SSIs only involves the skin surrounding the incision; others may be deeper and more serious [5].
During the 1950s, a severe epidemic of NI occurred in surgical units in Europe and America, but thanks to the beginning of antiseptic surgery and antibiotics as prophylaxis, the problem reduced a lot [6]. Despite the technological advances that have been made in surgery and wound management, wound infection has been regarded as the most common NI currently [7]. Surgical site infections are a major problem in developed countries, where it affects from 0.5% to 15% of hospitalized patients and as many as 50% or more of patients in Intensive Care Units (ICUs). The prevalence of NI in some developed countries, in the USA (15%), German and France (<3%) [8,9] and Brazil (16.9%) [10] were reported. In developing countries, the magnitude of the problem remains underestimated or even unknown largely because NI diagnosis is complex and surveillance activities to guide interventions require expertise and resources. A study conducted in Tanzania among patients undergoing major surgery reported 26% SSI [11]. In Ethiopia, different studies reported that the prevalence of post-surgical Abstract Nosocomial infection is an infection that acquired after exposure of patients to hospital for 48-72 hrs, but not present during admission. Surgical site infection is among the leading nosocomial infection that acquired after operation or admission. This review aims to determine the burden of NI in surgical site infection in Ethiopia systematically. Among a 167 mean of clinically suspected patients samples 9-92% were culture-confi rmed with a mean of 70.125 and median 67. Seven studies identifi ed 49.3-100% of culture-confi rmed infection as SSI; two studies reported BSI 2.2 & 20.8 percent and one study declare UTI as 29.8 percent among 77 cultures confi rmed and one study not reported about infection identifi ed. Ward type, type of operation, wound type, being a male, site of a wound, age ≥ 51, diabetes mellitus, anaemia, antibiotic usage after surgery, 11-15 days preoperative hospital stay, postoperative hospital stay; surgical procedure, urinary catheter, mechanical vent, IV catheter, longer duration from admission to discharge, longer duration of preoperative and preoperative prophylaxis identifi ed as potential risk factors. S. aureus and CoNS is among the leading gram-positive bacterial isolate and E. coli, Klebsiella spp, Proteus spp and P. aeruginosa are among gram-negative organisms that isolated from eight studies in Ethiopia.
Citation: Alemayehu T (2020) The burden of aerobic bacterial nosocomial infections, associated risk factors and antibiotic susceptibility patterns in a surgical site in Ethiopia: A systematic review. J Surg Surgical Res 6(2): 126-132. DOI: https://dx.doi.org/10.17352/2455-2968.000112 wound infection ranges from 14.8-60% [12][13][14][15]. The variation in prevalence might be due to the difference in the type of operation (obstetrics & gynaecology, general surgery and orthopaedic) and the underlying status of patients as well as the infection control practices of the hospital environment and the type of etiologic agent [9,16,17].
The most predominant bacteria in SSIs are S. aureus, Enterococcus spp, P. aeruginosa, E. coli, and other Enterobacterales.
Factors underlying for NI after surgery are multiple and include the type of surgical procedure, the skills of the surgeon, the duration of surgery and the underlying disease of the host [26]. Both infection and wound healing are adversely infl uenced by poorly controlled diabetes mellitus. Age is considered an important factor, neonates and the elderly are particularly at risk of infection. Lifestyle can also impinge on immuno-competency especially stress, alcohol and drug abuse, smoking and lack of exercise or sleep [27].
In Ethiopia, there are few studies conducted on SSI [15,22,[28][29][30][31][32][33]. This review provides a general overview of the burden of aerobic bacterial nosocomial infections, associated risk factors and antibiotic susceptibility patterns in a surgical site in Ethiopia based on the information available in the scientifi c literature.

Result
The PubMed search yielded 29 papers. Of these, 5 met the illegibility criteria and 3 studies from Google scholar added ( Figure 1).

Antibiotic resistance rate
Antibiotics resistance among gram positive and gramnegative bacteria occurred with different rates of resistance.
Total percent of antibiotics resistance for gram positive and negative bacteria that isolated from each sample for specifi c drug calculated and rates of resistance determined. Bacteria that showed resistance < 60% are low rates of resistance, 60-80% intermediate rates resistance, 81-99 % high rates of resistance and 100% fully resistance (Table 3).

Discussion
The small number of papers retrieved is evidence that little information is available on the burden of NI in the surgical site  [39].
In these review type of operation is identifi ed as a signifi cant risk factor with p<0.001 in emergency surgery only [22] and p<0.038 in all type of operation [32]. Type of operation also was assessed a study from China with the signifi cant association in emergency surgery with p<0.000 which agreed with this review. Lower rate of SSI reported in emergency operation compared to elective from Vietnam as opposed to the fi nding of this review [34]. Acquiring infection in emergency operation is due to low preoperative operation and use of antiseptics before surgery [40].  Age ≥ 51 (p < 0.033); diabetes mellitus (p < 0.018), anemia (p < 0.007); antibiotic usage after surgery (p < 0.02), 11-15 preoperative hospital stay (p < 0.03), post-operative hospital stay, 5-10 (p < 0.004), 11-15( Longer duration from admission to discharge (p < 0.008), longer duration of preoperative (p < 0.014); wound type (p < 0.029), ward type (p < 0.012); type of operation(p < 0.038) and preoperative prophylaxis (p < 0.   for the formation of NI [3].  [43], Gabon [44] and Nigeria [45] agreed with this review, but a study from Tanzania reported P.
aeruginosa as the most frequently isolated bacteria followed with S. aureus and K. pneumoniae [46].
For this review antibiotics, resistance classifi ed as those < 60% resistance for a specifi c drug as low-rates resistant, 60-

Author contribution
TA conceived the idea, reviewed available data and prepared the manuscript.

Availability of data and material
Can be obtained from the corresponding author.