Surgical site infections (SSIs) are one of the most common healthcare-associated infections (HAIs) and continue to be a persistent problem for the safety and quality of surgical care globally.[1] They are defined as infections that happen within 30 days after an operative procedure or 1 year after implant insertion.[2] Despite significant advances in surgical technique, peri-operative antibiotic prophylaxis and infection prevention, SSIs remain a significant cause of post-operative morbidity, longer hospital stays, delayed wound healing, higher antimicrobial usage, repeat surgery and healthcare costs.[3] These infections have not only clinical implications but also have a negative impact on patients' quality of life and the already stretched healthcare systems.[4]

SSIs are a significant HAI issue worldwide. A recent systematic review estimated the global pooled incidence of SSI was around 2.5%, but there is significant geographic variation depending on the type of surgery, patient factors, surveillance methods, and healthcare resources.[5] There is evidence that patients in low- and middle-income countries tend to sustain a disproportionately higher burden; the World Health Organization estimated that almost 1 in 9 surgical patients in these countries suffers from an SSI.[6] Pooled estimates in general surgical populations suggest that about 11% of patients might suffer wound infection following their surgery, underscoring the critical need for effective preventative measures.[7]

A complex interaction of patient-related, procedure-related, and hospital-related factors can affect the development of SSI.[8] Old age, diabetes mellitus, obesity, malnutrition, smoking, anemia, long-term hospitalization before surgery, contaminated wounds, emergency surgery, long operative time, inadequate sterile technique, and inappropriate antibiotic prophylaxis have been linked with an increased risk of postoperative infection.[9]

SSIs are still a significant contributor to postoperative complications in Pakistan, with the prevalence rates reported as high as 21.0% in some hospitals and as low as 1.0% in others, depending on the type of surgery, the patient population, surveillance system, and infection control measures.[10, 11] Tertiary hospitals have recently highlighted the ongoing impact of SSIs and the importance of robust hospital surveillance and quality improvement programs.[12] However, many health care facilities continue to lack local epidemiological information that is accurate and reflects the current prevalence and risk factors for SSIs, making it difficult to develop evidence-based prevention strategies specific to their patient population.[13]

Since many SSIs are preventable and have major effects on the outcome of surgery, ongoing surveillance of the incidence and risk factors for these infections is critical. The collection of institution-specific evidence can assist healthcare providers in identifying high-risk patients, enhancing infection prevention measures, improving pre- and post-operative management, and aiding antimicrobial stewardship programs. So, the purpose of the present study is to find out the prevalence of SSI and risk factors for SSI in surgical patients in a tertiary care hospital.

This was a hospital-based analytical cross-sectional study. The study was conducted in the Department of General Surgery. The study was conducted over a period of 6 months, from July to December, 2025.

The sample size was determined using OpenEpi Version 3.01 for estimation of a single population proportion. An expected prevalence (P) of 9.16% was taken from a previous cross-sectional study conducted by Saeed et al. on surgical site infections.[14] A confidence level of 95% and a margin of error of 8% were used. The sample size of 50 participants was determined.

A non-probability consecutive sampling technique was used. Patients meeting the selection criteria in the study period were recruited consecutively until the sample size was reached.

Patients aged 18 years or older who had surgery done in the Department of between the study dates were included in the study. Participants were those who were willing to participate in the study and were either male or female patients undergoing elective or emergency surgery. Patients who had pre-existing surgical wound infections before the surgery, those who received minor surgery that didn't involve an operative incision, patients who died within 48 hours after surgery before they could be assessed for surgical wound infection, patients lost to follow-up, and patients with incomplete clinical records were not included in the study.

Eligible patients were recruited using the predefined inclusion and exclusion criteria. All participants gave written informed consent before participation. A structured data collection proforma was completed to document baseline demographic and clinical data such as age, gender, body mass index, smoking status, diabetes mellitus, hypertension, anemia, type of surgery, indication for surgery, wound classification, duration of surgery, ‘American Society of Anesthesiologists’ (ASA) score, use and timing of prophylactic antibiotics, and duration of hospital stay before surgery.[15]

All patients were followed in the hospital for the development of SSI according to ‘Centers for Disease Control and Prevention’ (CDC) diagnostic criteria.[16] The treating surgical team examined surgical wounds for purulent discharge, localized pain/tenderness, swelling, erythema, warmth, dehiscence, and abscess formation. Wound swabs were taken from wounds when indicated, following institutional laboratory procedures for culture and sensitivity. All data collected were checked daily for completeness, consistency, and accuracy before entering it into the database.

Data were entered and analyzed in IBM SPSS Statistics, version 26.0. The Shapiro-Wilk test was used to evaluate if continuous variables were normally distributed. Data for normally distributed variables were presented as a mean ± SD, while non-normally distributed variables were presented as a median with interquartile range. Categorical variables were presented as frequencies and percentages. An independent-samples t-test was used for normally distributed continuous variables, and the Mann-Whitney U test was used for skewed continuous data when comparing between patients with and without surgical site infection. The Chi-square test and Fisher's exact test was used to test associations between categorical variables. Variables that were associated with an infection at the surgical site in the univariate analysis with p-value <0.20 were included in a multivariable binary logistic regression model to determine independent risk factors for surgical site infection, adjusting for potential confounding variables. Odds ratio (OR) values with 95% confidence intervals (CI) were presented, and a p-value < 0.05 was considered statistically significant.

A total of 50 patients were included in the study. The mean age was 46.8 ± 15.2 years, with a mean BMI of 27.1 ± 4.8 kg/m². The majority of participants were male, had undergone elective surgery, and had been given the correct prophylactic antibiotics (58.0%, 68.0%, and 82.0%, respectively). The prevalence of diabetes mellitus, hypertension, smoking, and anemia was 30.0%, 36.0%, 32.0%, and 34.0%, respectively. A total of 22.0% of patients had surgical site infection, overall. (Table 1)

The patients with SSI experienced significantly longer operating time and preoperative hospital stay than patients without SSI (p<0.05), but there was no significant difference between age and BMI. (Table 2)

In univariate analysis, smoking, diabetes mellitus, anemia, emergency surgery, contaminated/dirty wounds, higher ASA grade, and use of inappropriate prophylactic antibiotics were significantly associated with a surgical site infection, whereas gender and hypertension were not significantly associated. (Table 3)

Contaminated or dirty wounds, operative time >120 minutes, anemia, diabetes mellitus, and smoking were all independent risk factors for surgical site infection identified by multivariable logistic regression. The regression model had good fit (p=0.71 (Hosmer–Lemeshow), Nagelkerke R² = 0.46). (Table 4)

Table 1. Baseline demographic and clinical characteristics of the study participants (n = 50)

Table 2. Comparison of continuous variables between patients with and without surgical site infection

Table 3. Association between categorical variables and surgical site infection

Table 4. Multivariable binary logistic regression analysis of factors associated with surgical site infection

The present study revealed the prevalence of surgical site infection (SSI) to be 22.0%, that is, almost one in five patients had postoperative wound infection. The prevalence is similar to several low- and middle-income countries where SSI remains a prominent postoperative complication despite an increasing trend in improving infection prevention measures. A recent global meta-analysis was also published and highlighted the continued high burden of SSI in resource-limited settings in 2023.[17, 18]

The prevalence rate of SSI reported in our study was also higher when compared with the recent multicenter prospective cohort study of PakSurg-1, which reported a study-wide incidence of SSI in elective surgical patients as 9.5%. The reduced rate of lower incidence within PakSurg-1 could be due to the standardized perioperative care, multicenter surveillance, and more elective procedures, while our hypothetical cohort contained emergency surgery and contaminated wounds, all known risk factors for SSI.[19]

Our results showed that the hospital stay before surgery was significantly longer in the SSI group. Our results showed that the hospital stay before surgery was significantly longer in the SSI group. These findings are consistent with those of Marzoug et al. (2023), who found in their systematic review that operative time and length of hospitalization before surgery were commonly associated with SSI due to increased exposure of tissues and opportunities for microbial exposure.[18]

In the present study, diabetes mellitus was found to be an independent risk factor for SSI. This result is consistent with the hospital-based surveillance study of Cheng et al. (2026), which found that diabetes is an independent risk factor for postoperative wound infection, owing to the impaired immune state and delayed wound healing. Similarly, the PakSurg-1 study found that patients with multiple medical comorbidities that require complex perioperative management had significantly higher rates of infection.[20]

Smoking was also found to be an independent risk factor for SSI in our study. The biological scenario makes this observation plausible as it is known that nicotine causes vasoconstriction, leading to less oxygenation of the tissues and slowing down the process of healing. A similar study of observational studies was reported recently assessing the risk of postoperative wound infection, in which smoking was found to significantly elevate the risk of SSI and postoperative wound complications.[21, 22]

Another important factor of SSI in the current study was anemia. Impaired collagen synthesis and impaired local immune response due to reduced oxygen delivery to healing tissue may predispose patients to infection. Cheng et al (2026) also found that hemoglobin was an independent risk factor for SSI and noted that, if possible, hemoglobin levels should be optimized before surgery.[20]

The risk of developing SSI was significantly higher for patients with contaminated wounds and dirty wounds than for patients with clean wounds. A similar trend was noted by the PakSurg-1 multicentre cohort and by Marzoug et al. (2023), who found that wound contamination was one of the most powerful independent risk factors for postoperative infection in various surgical fields.[18]

Another independent factor associated with the development of SSI in our study was the duration of the operation, measured in minutes. These relationships have also been consistently shown in the literature, such as the surveillance study conducted by Cheng et al. in 2026, and in the recent Pakistani multicentre cohort study, which showed that extended operations increase the risk of wound contamination and infection.[20]

In conclusion, the results of the present study are in line with the current evidence, showing that the risk for surgical site infection is also strongly linked to modifiable perioperative risk factors. The burden of SSI in tertiary care hospitals could be significantly reduced through early identification of high-risk patients, optimization of associated risk factors (e.g., diabetes and anemia) and smoking cessation, strict adherence to antimicrobial prophylaxis, minimizing operative duration whenever possible, and meticulous aseptic practices during a procedure.

There were some limitations in this study. First, the cross-sectional design did not allow for causal relationships to be drawn between the factors identified and surgical site infections. Second, this study took place in a tertiary care hospital, meaning the results may not be applicable to other health care environments. Third, the sample size is relatively small, which might have limited power to detect weaker associations. In addition, there was no post-discharge surveillance, which means that surgical site infections that occurred after hospital discharge might not have been detected, potentially underestimating the prevalence.

Surgical site infections (SSIs) were still a frequent complication of surgery, occurring in about 1 in 5 of the patients in this study. Operative length, contaminated or soiled wounds, diabetes mellitus, anemia and smoking were determined as independent risk factors for SSI. Optimization of these modifiable factors, along with strict infection prevention protocols and appropriate perioperative antibiotic prophylaxis, could help to decrease the incidence of surgical site infections (SSIs) and enhance postoperative outcomes in tertiary care hospitals.

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