98
D. L. Teodorescu et al.
two to three billion have access only to surgeries performed in unsterile settings such
as general-use buildings or even outdoors (“Global Surgery 2030”, 2015; Disease
Control Priorities Project 2008). In addition to this chronic deficiency in surgical
access, field surgical zones in disaster-affected areas are often exposed to frank particulate and insect contamination.
9.1.2 Patient Safety in Surgery: Infrastructural Challenges
to Sterility
In LMICs, surgical patients develop disproportionate rates of surgical site infections (SSIs), particularly the deep infections characteristic of intraoperative contamination. Meta-analyses (Allegranzi et al. 2011) have found that 0.4–30.9 per
100 surgical patients in LMICs develop SSIs. In particular, even in clean and cleancontaminated wounds, which had not previously been contaminated by traumatic skin
breaks, uncontrolled gut flora spillage, etc., the median cumulative incidences were
still, respectively, 7.6% (range 1.3–79.0%) and 13.7% (1.5–81.0%), all several times
higher than in higher income countries (Ortega et al. 2011). Most alarmingly, these
figures represent early postoperative infections of deep visceral spaces and organs,
not superficial tissues, a finding underscored by Nejad et al. (2011) meta-analysis
that showed 6.8–46.5% incidence of deep infections in postoperative patients, and
10.4–20.5% of infections in organ spaces. Bjorklund et al. (2005) analysis showed a
particularly unfortunate interaction between immunosuppression—all too common
in the developing world due to poor nutrition, untreated illness, and HIV—and unsterile surgical conditions in producing very high rates of severe infection following
c-sections. These infections translate into longer stays at already-overcrowded hospitals: eight additional days on average in Tanzanian and Ethiopian studies, 10 days
in a Burkina Faso study comparing surgical patients with and without SSIs (Eriksen
et al. 2003; Taye 2005; Sanou et al. 1999). In nascent healthcare systems with limited infrastructures, SSIs that effectively double or triple patient stay lengths fetter
institutions’ ability to cope and reduce the volume of new patients that could be
accommodated. Taye (2005) noted that SSIs were associated with 2.8-fold increased
mortality (10.8% vs. 3.9%).
Numerous factors impact surgical site infection rates. These have been most
authoritatively summarized by the Lancet Commission on Global Surgery (2015) and
range from preoperative antibiotic administration to drape selection to handwashing
and beyond. A particularly pernicious and challenging one to address has been that of
the contaminated environment. Whyte et al. (1982) and Edmiston et al. (2005) have
described the general link between airborne contamination and SSIs, with an estimated 30–98% of wound bacteria attributable to airborne contaminants, depending
on the ventilation system in an operating room. In higher income countries, invasive
procedures are typically performed by scrub-attired personnel striving to reduce contamination in operating rooms with meticulously filtered air. In LMICs, such facil-
D. L. Teodorescu et al.
two to three billion have access only to surgeries performed in unsterile settings such
as general-use buildings or even outdoors (“Global Surgery 2030”, 2015; Disease
Control Priorities Project 2008). In addition to this chronic deficiency in surgical
access, field surgical zones in disaster-affected areas are often exposed to frank particulate and insect contamination.
9.1.2 Patient Safety in Surgery: Infrastructural Challenges
to Sterility
In LMICs, surgical patients develop disproportionate rates of surgical site infections (SSIs), particularly the deep infections characteristic of intraoperative contamination. Meta-analyses (Allegranzi et al. 2011) have found that 0.4–30.9 per
100 surgical patients in LMICs develop SSIs. In particular, even in clean and cleancontaminated wounds, which had not previously been contaminated by traumatic skin
breaks, uncontrolled gut flora spillage, etc., the median cumulative incidences were
still, respectively, 7.6% (range 1.3–79.0%) and 13.7% (1.5–81.0%), all several times
higher than in higher income countries (Ortega et al. 2011). Most alarmingly, these
figures represent early postoperative infections of deep visceral spaces and organs,
not superficial tissues, a finding underscored by Nejad et al. (2011) meta-analysis
that showed 6.8–46.5% incidence of deep infections in postoperative patients, and
10.4–20.5% of infections in organ spaces. Bjorklund et al. (2005) analysis showed a
particularly unfortunate interaction between immunosuppression—all too common
in the developing world due to poor nutrition, untreated illness, and HIV—and unsterile surgical conditions in producing very high rates of severe infection following
c-sections. These infections translate into longer stays at already-overcrowded hospitals: eight additional days on average in Tanzanian and Ethiopian studies, 10 days
in a Burkina Faso study comparing surgical patients with and without SSIs (Eriksen
et al. 2003; Taye 2005; Sanou et al. 1999). In nascent healthcare systems with limited infrastructures, SSIs that effectively double or triple patient stay lengths fetter
institutions’ ability to cope and reduce the volume of new patients that could be
accommodated. Taye (2005) noted that SSIs were associated with 2.8-fold increased
mortality (10.8% vs. 3.9%).
Numerous factors impact surgical site infection rates. These have been most
authoritatively summarized by the Lancet Commission on Global Surgery (2015) and
range from preoperative antibiotic administration to drape selection to handwashing
and beyond. A particularly pernicious and challenging one to address has been that of
the contaminated environment. Whyte et al. (1982) and Edmiston et al. (2005) have
described the general link between airborne contamination and SSIs, with an estimated 30–98% of wound bacteria attributable to airborne contaminants, depending
on the ventilation system in an operating room. In higher income countries, invasive
procedures are typically performed by scrub-attired personnel striving to reduce contamination in operating rooms with meticulously filtered air. In LMICs, such facil-