EC Clinical and Medical Case Reports

Background: After an emergency trauma laparotomy, surgical site infections (SSI) continue to be a leading cause of postoperative morbidity, especially in environments with limited resources and a history of violence. Due to extensive wound contamination, delayed presentation, and interruption of routine perioperative and infection prevention procedures, armed conflict increases the risk of infection.

Objectives: The purpose of this study is to ascertain the prevalence, trends, and contributing variables of surgical site infections after emergency trauma laparotomy in a healthcare system devastated by war, as well as to pinpoint useful areas for infection control in austere emergency surgical settings.

Methods: Three major Gaza Strip referral hospitals participated in a prospective cohort study from October to December 2023. We considered successive violent injury victims who had emergency laparotomies. Prospective clinical, surgical, injury-related, and demographic data were collected. Within 14 days after surgery, surgical site infections were evaluated according to the Centers for Disease Control and Prevention's criteria. The Chi-square test was used to assess relationships between possible risk variables and the incidence of SSI.

Findings: There were 126 patients in all. The incidence of SSI was 34.7% overall. The most prevalent kind of incisional infection was superficial, which was followed by deep and organ/space infections. The development of SSI was substantially correlated with wound categorization, with contaminated wounds showing greater infection rates than dirty wounds (p = 0.013). There were no statistically significant correlations found between SSI and the existence of other injuries, smoking status, length of operation, or patient comorbidities. Culture-positive infections were primarily caused by gram-negative organisms, and SSI was linked to longer hospital stays and readmissions due to infection.

Conclusion: In conclusion, wound contamination and system-level limitations are the main causes of the significant early SSI burden linked to emergency trauma laparotomy in conflict situations. In health systems damaged by conflict, specific, workable infection control measures are necessary to lower postoperative morbidity and maintain emergency surgical capacity.

Keywords: Surgical Site Infection; Emergency Surgery; Trauma Laparotomy; War-Related Injury; Resource-Limited Settings

Abbreviations: SSI: Surgical Site Infections; CDC: Centers for Disease Control and Prevention's

1. Allegranzi Benedetta., et al. “New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective”. The Lancet Infectious Diseases12 (2016): e276-e287.
2. Ban Kathryn A., et al. “American college of surgeons and surgical infection society: surgical site infection guidelines, 2016 update”. Journal of the American College of Surgeons1 (2017): 59-74.
3. Anderson Deverick J., et al. “Strategies to prevent surgical site infections in acute care hospitals: 2014 update”. Infection Control and Hospital Epidemiology5 (2016): 501-523.
4. Berríos-Torres Sandra I., et al. “Centers for disease control and prevention guideline for the prevention of surgical site infection, 2017”. JAMA Surgery8 (2017): 784-791.
5. Merkow Robert P., et al. “Underlying reasons associated with hospital readmission following surgery in the United States”. JAMA5 (2015): 483-495.
6. Allegranzi Benedetta., et al. “Global infection prevention and control priorities 2018-2022: A WHO perspective”. The Lancet Global Health12 (2017): e1174-e1186.
7. Abdeen Moataz., et al. “Conflicts in Gaza and around the world create a perfect storm for infectious disease outbreaks”. The Lancet Infectious Diseases4 (2022): 456-457.
8. Clarke Alexander., et al. “Accurate risk stratification for development of organ/space surgical site infections after emergent trauma laparotomy”. Journal of Trauma and Acute Care Surgery6 (2018): 987-994.
9. von Elm Erik., et al. “The STROBE statement: updated guidelines for reporting observational studies”. International Journal of Surgery 63 (2019): 100-107.
10. Centers for Disease Control and Prevention. National Healthcare Safety Network (NHSN) Surgical Site Infection Event. CDC (2024).
11. Murray Clinton K., et al. “Prevention and management of infections associated with combat-related injuries”. Journal of Trauma and Acute Care Surgery3.1 (2017): S235-S257.
12. Kim Hyeon-Yong. “Statistical Notes for Clinical Researchers: Chi-Square Test and Fisher’s Exact Test”. Restorative Dentistry and Endodontics2 (2017): 152-155.
13. World Medical Association. “World Medical Association Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects”. JAMA20 (2018): 2191-2194.
14. Isbell Kent D., et al. “Risk stratification for superficial surgical site infection after emergency trauma laparotomy”. Journal of Trauma and Acute Care Surgery (2021).
15. Papadopoulos Antonios., et al. “Risk factors for surgical site infections: emergency surgery”. In Vivo6 (2021): 3569-3576.
16. Acker Adam., et al. “Leaving contaminated trauma laparotomy wounds open: outcomes and resource utilization”. Journal of Surgical Research 232 (2018): 450-455.
17. Lowe Helen., et al. “Challenges and opportunities for infection prevention and control in hospitals in conflict-affected settings: a qualitative study”. Conflict and Health1 (2021): 94.
18. Wren Sarah M., et al. “A consensus framework for the humanitarian surgical response in areas of armed conflict”. JAMA Surgery2 (2020): 121-128.
19. Spiegel Paul B., et al. “The humanitarian crisis in Gaza: Barriers to surgical care and health system resilience”. The Lancet10374 (2023): 236-238.