Surgical site infections after tissue flaps performed in Low and Middle Human Development Index Countries: A systematic review


Surgical Infections


Lawrence Cai
James Chang

Date Published: October 2017
Quality Improvement
Tissue Flaps

Background: Surgical site infections (SSIs) affect the safety of surgical care and are particularly problematic and prevalent in low and middle Human Development Index Countries (LMHDICs).

Methods: We performed a systematic review of the existing literature on SSIs after tissue flap procedures in LMHDICs through the PubMed, Ovid, and Web of Science databases. Of the 405 abstracts identified, 79 were selected for full text review, and 30 studies met inclusion criteria for analysis.

Results: In the pooled analysis, the SSI rate was 5.8 infections per 100 flap procedures (95% confidence interval [CI] 2%–10%, range: 0–40%). The most common indication for tissue flap was pilonidal sinus repair, which had a pooled SSI rate of 5.6 infections per 100 flap procedures (95% CI 2%–10%, range: 0–15%). No fatalities from an infection were noted. The reporting of infection epidemiology, prevention, and treatment was poor, with few studies reporting antibiotic agent use (37%), responsible pathogens (13%), infection comorbidities (13%), or time to infection (7%); none reported cost.

Conclusions: Our review highlights the need for more work to develop standardized hospital-based reporting for surgical outcomes and complications, as well as future studies by large, multi-national groups to establish baseline incidence rates for SSIs and best practice guidelines to monitor SSI rates.

Surgical site infections are challenging and affect the safety of surgical care; they are particularly problematic and prevalent in low- and middle-Human Development Index Countries (LMHDICs) [1,2]. Recent estimates of the global incidence of surgical site infections (SSIs) range from 1.2 to 23.6 per 100 surgical procedures, with particularly high rates noted in developing countries [3]. Local flaps, regional flaps, distant flaps, and free flaps are surgical procedures that use safe flap reconstruction, repair, and coverage of a wide range of pathologic conditions spanning trauma, burns, and cancer. Despite their versatility, safe flap construction is highly complex and requires significant healthcare infrastructure to be successful.

One component of this care is prevention of post-surgical infection. Infection can result in increased antibiotic agent use, extended hospital stays, flap loss, re-operation, and, in extreme cases, death. While the rate of SSIs after flap procedures in high Human Development Index Countries (HHDICs) is well described [4,5], less is known about the incidence of SSIs after flap procedures in LMHDICs.

To help address this deficit, we performed a prospectively registered systematic review of the existing literature on SSIs after surgical flap procedures in LMHDICs. Articles describing local or free flap procedures in these countries were critically evaluated to assess baseline SSI incidence and mortality rates and establish a potential benchmark for future studies.