|Year : 2016 | Volume
| Issue : 2 | Page : 198-201
A prospective study of wound infection among post-discharge patients at a level 1 trauma centre of India
K Sharma1, BT Thanbuana1, AK Gupta1, N Rajkumari2, P Mathur3, J Gunjiyal1, MC Misra4
1 Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
2 Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
3 Department of Laboratory Medicine, Division of Clinical Microbiology, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
4 Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
|Date of Submission||28-Nov-2014|
|Date of Acceptance||19-Jan-2016|
|Date of Web Publication||14-Apr-2016|
Department of Laboratory Medicine, Division of Clinical Microbiology, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
Background and Aim: To study the rate of wound infections in the post-discharged patient population and to assess the usefulness of post-discharge surveillance. Methods: A prospective surveillance of all the post-discharged trauma patients was done during a period of 6 months. Discharge instructions were given to all the patients regarding identification of the signs and symptoms of wound infections. They were telephonically followed up after a week to enquire about the wound condition and followed up in the outpatient department (OPD). Microbiology culture samples of those showing any signs and symptoms of infections were sent and their antimicrobial therapy, any change in the treatment schedule and the length of their hospital stay were noted. Factors such as wound class, type of surgeries and readmissions were noted. Results: A total of 281 postdischarge patients were enrolled, of which 101 were completely followed up for wound infections. Males were predominant (89%). Of the 101 patients, 42 (41.6%) patients wound showed infection during the intense follow-up in the OPD. However, 59 patients (59/101, 58.4%) showed wound swab culture positivity before discharge. These 42 patients developed signs and symptoms of infection post-discharge; 23 (22.7%) of them had change of antibiotic therapy during the follow-up period due to culture positivity. Acinetobacter sp., Staphylococcus aureus and Klebsiella pneumoniae were the predominant organisms isolated in the study. A total of 45 patients (44.5%) had to be readmitted due to wound site infections. Conclusions: Wound infections are common after discharge among trauma patients highlighting the importance of active surveillance and participation of patients.
Keywords: Post-discharge, surgery, surveillance, telephonic contact, wound infections
|How to cite this article:|
Sharma K, Thanbuana B T, Gupta A K, Rajkumari N, Mathur P, Gunjiyal J, Misra M C. A prospective study of wound infection among post-discharge patients at a level 1 trauma centre of India. Indian J Med Microbiol 2016;34:198-201
|How to cite this URL:|
Sharma K, Thanbuana B T, Gupta A K, Rajkumari N, Mathur P, Gunjiyal J, Misra M C. A prospective study of wound infection among post-discharge patients at a level 1 trauma centre of India. Indian J Med Microbiol [serial online] 2016 [cited 2019 Jun 17];34:198-201. Available from: http://www.ijmm.org/text.asp?2016/34/2/198/180299
| ~ Introduction|| |
Surgical site infections (SSIs) are one of the most common health care associated infections (HCAIs), causing substantial morbidity, with 2-11-fold higher mortality. SSIs complicate 300,000-500,000 surgeries per year in the USA alone and are believed to result in $5-10 billion of excess health expenditures, along with increased length of hospital stay. , SSI rates have become a universal measure of quality in hospital-based surgical practice, since they are probably the most preventable of all HCAIs. Therefore, regulatory bodies have made it mandatory to report SSI rates in many countries. The figures of SSI burden are likely to be significant underestimates because most hospitals truncate SSI surveillance at the time the patient leaves hospital, which is problematic because many infections emerge following discharge. In elective surgeries, approximately, 50-80% of SSIs manifest after discharge. Of these, 90% manifest within 4 weeks. Thus, failure to collect post-discharge data significantly underestimates SSI burden. There is a trend towards early discharge of patient from hospitals owing to increasing tendency towards home-based and day care treatment. As a result, many post-operative wound infections do not become apparent until several days after discharge.  In developing nations, patients are unable to come for follow-up to the outpatient clinics as most of them are from outside the city which makes repeated visits costly. Patients are usually daily wagers and prefer to go to their local hospitals.  Thus, there are more chances of missing out wound infections. Trauma patients are otherwise healthy, predominantly belonging to the socioeconomically productive age group of the society.
Surveillance and feedback are highly cost-effective means of reducing HCAI rates in health care set-ups. These programmes require reliable HCAI rates, delivered in a timely manner and as efficiently as possible. From the Indian perspective, there is a stark lacuna of a proper, standardised and validated surveillance system for SSIs, incorporating the element of post-discharge surveillance. The development of a national surveillance system remains a distant goal for want of small, feasibility studies, which would form a base to build up such system. We have recently developed an indigenous, automated surveillance system for device-associated infections at our centre, which has helped in reduction of those infections. 
Ours being a level-1 trauma centre, a significant amount of trauma patients are referred from all over India. A review of literature shows very few studies dealing with post-discharge development of SSI,  especially among poly-trauma patients discharged with healthy wounds.
In view of the lacunae in literature, along with the need to ultimately develop systematic surveillance systems for SSIs in developing countries such as India, the present study was undertaken to assess the prevalence of wound infections in post-discharge trauma patients admitted to a level-1 trauma centre of a developing country. We assessed the feasibility of telephonic follow-up at our referral trauma centre.
| ~ Methods|| |
The Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, is operational since 2007. It has 172 beds, with an average total admission of 4094 patients and 50,137 emergency visits per year. The study was conducted prospectively in a cohort of consecutive poly-trauma patients with surgical, neurosurgical and orthopaedic trauma admitted to the trauma centre for a period of 6 months, from April to September, 2013. Their duration of hospital stay, nature of the trauma and any related infections developing during hospital stay were noted. The demographic and clinical data such as age, gender, type of trauma, date of injury, date of admission, associated injuries, final diagnosis, surgeries undergone, date of discharge, treatment details and outcomes were recorded and analysed.
Discharge instructions were given to all the patients regarding identification of the signs and symptoms of wound infections by a dedicated hospital infection control nurse. All patients who had been discharged were telephonically followed up after a week to enquire about the wound condition and followed up in the outpatient department (OPD) till their wound healed or till they got re-admitted due to wound-related complications. Samples were taken for microbiological culture from those patients who showed any signs and symptoms of infections. The change in antimicrobial therapy, if any and the length of their hospital stay were noted.
The type of wound was classified as per Centres for Disease Control's criteria.  Factors such as wound class, type of surgeries and readmissions were also recorded. The study was approved by the Institute's Ethical Committee.
| ~ Results|| |
A total of 281 postdischarged patients were included during the study period. Of these, 101 could be followed up for wound infections after discharge. Of the 281 patients, wound swabs of 59 patients (21%) were positive for one or more pathogens.
Of the 101 patients who could be followed up after discharge, 89 were males (88%). A total of 40 of these 101 patients were admitted to the surgical speciality, 25 to neurosurgery and 29 to orthopaedics. During the intensive post-discharge follow-up of the 101 patients, 42 (41.6%) were found to develop new wound infections. All 42 patients (41.6%) detected during follow-up, developed signs and symptoms of infection only during post-discharge period. Of these, 23 (55%) patients had change of antibiotic therapy during the follow-up period, based on the wound culture report.
Of the 101 patients, a total of 45 patients (44.6%) had to be re-admitted due to wound site infections and its complications. A few of these patients were discharged with wound infections and the rest were newly developed infections.
Escherichia More Details coli (16.7%) followed by Staphylococcus aureus (14.6%) were the most common organisms isolated from wound culture during the hospitalisation period. During the post-discharge period, S. aureus (38%) was more common than E. coli (14%), which may be pointing to community acquisition of infection. A comparison between the various organisms isolated during hospitalisation and post-discharge is shown in [Figure 1].
|Figure 1: Comparison of organisms isolated between the pre- and post-discharge patients (%)|
Click here to view
It was seen that the bacterial isolates obtained during the hospital stay were multi-drug resistant with the highest number of resistance seen among Acinetobacter sp., Klebsiella sp. and Pseudomonas sp. Gram-negative bacteria outnumbered Gram-positive bacteria among the organisms isolated from the wound samples of the patients during hospital stay. However, the reverse was seen from the isolates obtained during the post-discharge patients where Gram-positive bacteria were more. Among the Gram-negative bacteria (n = 51), 23 (45%) were resistant to imipenem, 42 (82%) to ceftazidime, 15 (29%) to amikacin and 18 (35%) to ciprofloxacin. A total of 2 (4%) were resistant to polymyxin. Among the Gram-positive bacteria which mainly comprised S. aureus (n = 38), 24 (63%) were resistant to amoxicillin/clavulanic acid, 28 (74%) to oxacillin, 18 (47%) to erythromycin, 16 (42%) to clindamycin and none to vancomycin. Thus, methicillin-resistant S. aureus (MRSA) contributes a major role in the wound infections in our study. It can hence be said that it is a multi-drug resistant S. aureus because resistance to oxacillin or cefoxitin infers nonsusceptibility to a wide range of beta lactamases (categories of penicillins, cephalosporins, β-lactamase inhibitors and carbapenems).  However, no isolates of vancomycin intermediate S. aureus or vancomycin-resistant S. aureus were recovered from the wound infections. Extended spectrum beta lactamases production were observed in many isolates of Gram-negative bacteria such as E. coli and Klebsiella sp., but their phenotypic and molecular characterisation is still an ongoing part of a larger study which is in progress.
| ~ Discussion|| |
In this study, a substantial number of wound infections were detected during post-discharge period, which are often missed in hospital-based surveillance. This emphasises the need for establishment of post-discharge surveillance programs, especially in surgical and trauma set-ups. 
Under-estimating post-discharge SSIs can lead policy makers to neglect their total population health impact, clinicians to discharge at-risk patients without appropriate follow-up and analysts to make inappropriate inter-hospital comparisons. Moreover, existing SSI risk prediction tools, which are derived from in-hospital surveillance systems, may be poor predictors of post-discharge infections. Given that the average length of stay after major surgical procedures continues to decrease, robust post-discharge surveillance needs to be initiated using trained and committed personnel, to generate accurate data. Studies have shown that MRSA varies from 20% to 54.8% in different parts of India, ,,, and our study's finding also falls within this range.
Surveillance of wound infections using telephone calls is applicable in developing countries and can be used as an alternative method to clinic-based diagnosis of wound infections.  For this, it is essential to instruct the patients at discharge in local vernacular language regarding the signs and symptoms of SSI. ,
Our study also showed that 44.5% patients came back with various wound-related complaints after discharge, which has also been seen in other set-ups. 
Surveillance of SSI is often an integral part of organisational infection prevention and control activities. Surveillance alone, along with feedbacks can significantly bring down the rates of SSI.  Especially for SSIs, the element of post-discharge surveillance should be added to generate country-specific risk prediction tools. India is currently facing a massive surge in multi-resistant pathogens causing HCAIs. Therefore, development of an antimicrobial prescription policy based on local data is a government priority, in the right spirit of Chennai Declaration. , Gathering of local data for putting a staunch antimicrobial policy in place can start with smaller studies, in which the role of peri-operative prophylaxis as the most common indicator of hospital antimicrobial prescription practices can be explored. The main purpose of this study was to identify the applicability of telephone calls in a low resource set-up as well as to assess to what magnitude we may be missing-out SSI, if post-discharge wound infection surveillance is not done.
| ~ Conclusion|| |
We conclude that post-discharge surveillance for wound infections and those of SSIs either through OPD follow-up or through telephonic contact was found to be very useful and hence should be included in the routine hospital surveillance protocol.
The authors would like to thank All India Institute of Medical Sciences, New Delhi, for supporting this study. The authors also extend their gratitude to the team of Hospital Infection Control Unit without which this study would not have been possible.
Financial support and sponsorship
The study was partly funded by a grant from Indian Council of Medical Research, New Delhi.
Conflicts of interest
There are no conflicts of interest.
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