Sample characteristics
A total of 6046 participants with the average age of 49.88±16.99 year-old were included in our study. The average length of hospitalization and average surgical time were 12.35±7.92d and 202.53±99.19min, the average length of SSI occurrence was 7.57±6.50d. The ASA score and NNIS risk index of the majority of surgical patients were level 2 (69.35%) and score 2 (52.15%). Most of the surgeries were selective surgery (83.59%), and the main infection site was organ/space infection (95.04%). The overall SSI rate of class I incisional surgeries was 2.00. Significant difference of infection was only found in the infections with various NNIS risk indexes (P=0.000). The details were in Table 1.
Table 1. The demographic characteristics of participants.
Variable
|
n (%) or
X ± SD
|
Number of SSI infection
|
Infection rate (%)
|
P-value
|
N
|
6046
|
121
|
2.00
|
|
Age (year-old)
|
49.88±16.99
|
|
|
|
Length of hospitalization (d)
|
12.35±7.92
|
|
|
|
Surgical time (min)
|
202.53±99.19
|
|
|
|
Length of SSI occurrence (d)
|
7.57±6.50
|
|
|
|
Gender
|
Male
|
3207 (53.00)
|
55
|
1.71
|
0.157
|
|
Female
|
2839 (47.00)
|
66
|
2.32
|
|
ASA score
|
1
|
151 (2.50)
|
2
|
1.32
|
0.890
|
|
2
|
4193 (69.35)
|
87
|
2.07
|
|
|
3
|
1420 (23.49)
|
28
|
1.97
|
|
|
4
|
267 (4.42)
|
4
|
1.50
|
|
|
5
|
15 (0.25)
|
0
|
0.00
|
|
NNIS risk index
|
0
|
2087 (34.52)
|
18
|
0.86
|
0.000
|
|
1
|
3153 (52.15)
|
83
|
2.63
|
|
|
2
|
806 (13.33)
|
20
|
2.48
|
|
Surgical type
|
Emergency surgery
|
993 (16.41)
|
16
|
1.61
|
0.337
|
|
Selective surgery
|
5053 (83.59)
|
105
|
2.08
|
|
Surgical infection site
|
Organ/Space infection
|
115 (95.04)
|
|
|
|
|
Deep incisional infection
|
2 (1.65)
|
|
|
|
|
Superficial incisional infection
|
4 (3.31)
|
|
|
|
The analysis of SSI
The monthly SSI rates fluctuated from 0.30% to 4.49%, which were shown in Figure 2. The crude and CMI-adjusted SSI rates in different departments were listed in Figure 3. The crude SSI rates ranked from high to low by department were department I (4.44%), IV (3.01%), V (2.18%), II (1.78%), ICU (1.68%), VI (1.39%), and III (0.99%). And the CMI-adjusted SSI rates by department were department I (0.80%), IV (0.65%), V (%), VI (0.46%), II (0.34%), ICU (0.26%), and III (0.15%). The ranking differences mainly observed in department II, VI and ICU. To be specific, department IV had the relatively lower difficulty of medical treatment and economic expenses, so its CMI-adjusted SSI rate was relatively high compared with the crude rate. On the contrary, department II had higher crude SSI rate, but its CMI-adjusted SSI rate was relatively low, implicating the higher treatment difficulty and economic expenses in this department. The detailed data of SSI adjustment by CMI values could be found at Table S2.
A total of 121 infection cases were summarized in our study. We firstly analyzed the infection sites stratified by NNIS risk indexes (see Table 2). Of the 121 infections, 115 cases were organ/space infection, and 83 cases (68.60%) belonged to score 1 of the NNIS risk index. Most of the organ/space infections occurred in score 1 of the NNIS risk index (n=80, 69.57%), 2 cases of deep incisional infections were located in score 0 and score 1 of the NNIS risk index, and 4 cases of superficial incisional infection were individually located in score 0 (n=1), score 1 (n=2), and score 2 (n=1) of the NNIS risk index.
Table 2. The SSI rate of different infection site with different NNIS risk indexes.
Surgical infection site
|
NNIS risk index (n (%))
|
0
|
1
|
2
|
In total
|
Organ/Space infection
|
16(13.91)
|
80 (69.57)
|
19 (16.52)
|
115
|
Deep incisional infection
|
1 (50.00)
|
1 (50.00)
|
0
|
2
|
Superficial incisional infection
|
1 (25.00)
|
2 (50.00)
|
1 (25.00)
|
4
|
In total
|
18 (14.88)
|
83 (68.60)
|
20 (16.53)
|
121
|
Our analysis confirmed the overall crude and NNIS risk index-adjusted SSI rate were 2.00% and 0.04%. We also evaluated the SSI rate of different surgical classifications and various surgeons. We firstly classified all surgeries into 17 categorizations. The most common surgery classification was resection of space occupying lesions (n=3746, 61.96%), followed by skull/dural repair surgery (n=370, 6.12%) and electrical stimulation electrode replacement surgery (n=273, 4.52%). The highest and lowest crude infection rates were found in hybrid operation (11.67%) and bone graft fusion and internal fixation surgery (0.46%). Similarly, the highest and lowest NNIS risk index-adjusted SSI rates were observed in resection of space occupying lesions (0.06%) and endoscopy-assisted resection of space occupying lesions (13.33%). No SSI was found in electrical stimulation electrode replacement surgery (n=273, 4.52%), craniotomy/spinal canal decompression surgery (n=143, 2.37%), endoscopy-assisted craniotomy evacuation of hematoma (n=122, 2.02%), endoscopy-assisted craniotomy decompression surgery (n=108, 1.79%), arterio-synagiosis surgery (n=73, 1.21%), neurolysis surgery (34, 0.56%), and internal fixation device implantation/removal surgery (n=17, 0.28). Detailed information were shown in Table 3. We secondly analyzed the SSI rate by surgeons, the detailed statistics were exported in Table S3. A total of 54 surgeons were summarized, of which 21 surgeons had SSI after surgery. The highest and lowest crude infection rates were found in surgeon 34 (50.00%) and surgeon 13 (0.58%). Similarly, the highest NNIS risk index-adjusted SSI rate was observed in surgeon 30 and 34 (50.00%), and the lowest NNIS risk index-adjusted SSI rate was found in surgeon 1 (0.21%) (See Figure 4).
Table 3. The SSI rate of different surgical classifications stratified by NNIS risk index.
Surgical classification
|
Total surgical cases (n (%))
|
NNIS risk index
|
Crude infection rate (%)
|
Average risk index
|
NNIS risk index-adjusted SSI rate (%)
|
0
|
1
|
2
|
Surgical cases
|
Infection cases
|
Infection rate (%)
|
Surgical cases
|
Infection cases
|
Infection rate (%)
|
Surgical cases
|
Infection cases
|
Infection rate (%)
|
Resection of space occupying lesions
|
3746 (61.96)
|
1289
|
16
|
1.24
|
2084
|
61
|
2.93
|
373
|
9
|
2.41
|
2.30
|
40.34
|
0.06
|
Skull/dural repair surgery
|
370 (6.12)
|
181
|
0
|
0.00
|
149
|
2
|
1.34
|
40
|
1
|
2.50
|
0.81
|
0.91
|
0.89
|
Electrical stimulation electrode replacement surgery
|
273 (4.52)
|
119
|
0
|
0.00
|
121
|
0
|
0.00
|
33
|
0
|
0.00
|
0.00
|
0.00
|
/
|
Craniotomy evacuation of hematoma
|
269 (4.45)
|
21
|
0
|
0.00
|
99
|
0
|
0.00
|
149
|
2
|
1.34
|
0.74
|
1.11
|
0.67
|
Arterial and venous embolization
|
217 (3.59)
|
104
|
0
|
0.00
|
92
|
3
|
3.26
|
21
|
2
|
9.52
|
2.30
|
1.47
|
1.57
|
Bone graft fusion and internal fixation surgery
|
216 (3.57)
|
81
|
0
|
0.00
|
119
|
1
|
0.84
|
16
|
0
|
0.00
|
0.46
|
0.55
|
0.84
|
Lumboperitoneal/ventricular
-peritoneal shunt
|
145 (2.40)
|
83
|
1
|
1.20
|
58
|
2
|
3.45
|
4
|
0
|
0.00
|
2.07
|
1.37
|
1.51
|
Craniotomy/spinal canal decompression surgery
|
143 (2.37)
|
27
|
0
|
0.00
|
73
|
0
|
0.00
|
43
|
0
|
0.00
|
0.00
|
0.00
|
/
|
Intraventricular trepanation and drainage surgery
|
133 (2.20)
|
41
|
1
|
2.44
|
84
|
2
|
2.38
|
8
|
0
|
0.00
|
2.26
|
1.57
|
1.44
|
Endoscopy-assisted craniotomy evacuation of hematoma
|
122 (2.02)
|
11
|
0
|
0.00
|
77
|
0
|
0.00
|
34
|
0
|
0.00
|
0.00
|
0.00
|
/
|
Endoscopy-assisted craniotomy decompression surgery
|
108 (1.79)
|
53
|
0
|
0.00
|
51
|
0
|
0.00
|
4
|
0
|
0.00
|
0.00
|
0.00
|
/
|
Incarceration of aneurysm
|
94 (1.55)
|
9
|
0
|
0.00
|
46
|
5
|
10.87
|
39
|
4
|
10.26
|
9.57
|
4.11
|
2.33
|
Arterio-synagiosis surgery
|
73 (1.21)
|
20
|
0
|
0.00
|
34
|
0
|
0.00
|
19
|
0
|
0.00
|
0.00
|
0.00
|
/
|
Hybrid operation
|
60 (0.99)
|
5
|
0
|
0.00
|
38
|
6
|
15.79
|
17
|
1
|
5.88
|
11.67
|
4.08
|
2.86
|
Neurolysis surgery
|
34 (0.56)
|
19
|
0
|
0.00
|
14
|
0
|
0.00
|
1
|
0
|
0.00
|
0.00
|
0.00
|
/
|
Endoscopy-assisted resection of space occupying lesions
|
26 (0.43)
|
11
|
0
|
0.00
|
10
|
1
|
10.00
|
5
|
1
|
20.00
|
7.69
|
0.58
|
13.33
|
Internal fixation device implantation/removal surgery
|
17 (0.28)
|
13
|
0
|
0.00
|
4
|
0
|
0.00
|
0
|
0
|
/
|
0.00
|
0.00
|
/
|
In total
|
6046 (100)
|
2087
|
18
|
0.86
|
3153
|
83
|
2.63
|
806
|
20
|
2.48
|
2.00
|
52.16
|
0.04
|
Pathogenic Results
Additional analysis of the distribution characteristics of pathogenic results was listed in our study (see Table 4). 44 of 121 SSI cases had confirmed pathogenic results from the cerebrospinal fluid examination for the evidence of SSI. A total of 57 types of pathogens were detected, the most common pathogenic bacterium were Staphylococcus epidermidis (n=13, 22.81%), Staphylococcus capitis (n=10, 17.54%) and Staphylococcus hominis (n=9, 15.79%).
Table 4. The distribution of pathogens.
Pathogen
|
n (%)
|
Gram-positive bacteria
|
Staphylococcus epidermidis
|
13 (22.81)
|
|
Staphylococcus capitis
|
10 (17.54)
|
|
Staphylococcus hominis
|
9 (15.79)
|
|
Staphylococcus cohnii
|
2 (3.51)
|
|
Corynebacterium
|
1 (1.75)
|
|
Staphylococcus caprae
|
1 (1.75)
|
|
Micrococcus luteus
|
1 (1.75)
|
|
Micrococcus lylae
|
1 (1.75)
|
|
Microbacterium
|
1 (1.75)
|
|
Staphylococcus haemolyticus
|
3 (5.26)
|
|
Acinetobacter baumannii
|
3 (5.26)
|
Gram-negative bacteria
|
Klebsiella pneumoniae
|
3 (5.26)
|
|
Pantoea agglomerans
|
1 (1.75)
|
|
Klebsiella aerogenes
|
1 (1.75)
|
|
Chryseobacterium gleum
|
1 (1.75)
|
|
Adhesive sphingomonas
|
1 (1.75)
|
|
Serratia marcescens
|
1 (1.75)
|
|
Sphingomonas paucimobilis
|
1 (1.75)
|
|
Enterobacter cloacae
|
1 (1.75)
|
|
Rothia mucilaginosa
|
1 (1.75)
|
Fungus
|
Fusarium
|
1 (1.75)
|
In total
|
57 (100)
|
Prophylactic usage of antibiotics
Finally, we analyzed the characteristics of perioperative prophylactic usage of antibiotics. The monthly usage rates of prophylactic antibiotics were displayed in Figure 5. Due to the relatively high risk of infections after surgery, the fairly high rate of perioperative prophylactic usage of antibiotics fluctuated from 76.96% to 96.95% by month was observed in our study. A sum of 17 kinds and 36 types of antibiotics were listed (see Table 5). The most commonly used antibiotics was Cefazolin (n=4170, 51.95%) and Cefuroxime (n=1060, 13.21%), which indicated the first generation cephalosporins were routinely used for perioperative prophylaxis. Besides, the analysis of correlation between SSI and prophylactic usage of antibiotics by month was performed (as shown in Figure 6). We found no significant associations for SSI and prophylactic usage of antibiotics (r=0.157, P=0.464).
Table 5. The distribution of perioperative prophylactic antibiotics type.
Antibiotics type
|
n (%)
|
First generation cephalosporins
|
Cefazolin
|
4170 (51.95)
|
Second generation cephalosporins
|
Cefuroxime
|
1060 (13.21)
|
Cefoxitin
|
3 (0.04)
|
Third generation cephalosporins
|
Cefoperazone sulbactam
|
633 (7.89)
|
Ceftriaxone
|
233 (2.90)
|
Ceftazidime
|
143 (1.78)
|
Cefdinir
|
9 (0.11)
|
Cefixime
|
7 (0.09)
|
Cefotaxime
|
1 (0.01)
|
Glycopeptides
|
Vancomycin
|
553 (6.89)
|
Norvancomycin
|
31 (0.39)
|
Carbapenems
|
Meropenem
|
326 (4.06)
|
Biapenem
|
89 (1.11)
|
Imipenem cilastatin
|
43 (0.54)
|
Penicillins
|
Oxacillin
|
255 (3.18)
|
Penicillin
|
4 (0.05)
|
Amoxicillin
|
1 (0.01)
|
Quinolones
|
Levofloxacin
|
136 (1.69)
|
Moxifloxacin
|
80 (1.00)
|
Piperacillin tazobactam
|
55 (0.69)
|
Penicillin compound preparation
|
Amoxicilin sodium and clavulanate potassium
|
33 (0.41)
|
Sitafloxacin
|
5 (0.06)
|
Oxazolidinones
|
Linezolid
|
66 (0.82)
|
Aminoglycosides
|
Amikacin
|
15 (0.19)
|
Gentamicin
|
5 (0.06)
|
Tetracyclines
|
Tigecycline
|
16 (0.20)
|
Lincosamides
|
Clindamycin
|
16 (0.20)
|
Antifungal agents
|
Voriconazole
|
8 (0.10)
|
Fluconazole
|
5 (0.06)
|
Caspofungin
|
2 (0.02)
|
Imidazole derivatives
|
Ornidazole
|
8 (0.10)
|
Metronidazole
|
3 (0.04)
|
Levononidazole
|
2 (0.02)
|
Oxacephems
|
Moxalactam
|
5 (0.06)
|
Polymyxins
|
Polymyxin B
|
3 (0.04)
|
Macrolides
|
Azithromycin
|
3 (0.04)
|
In total
|
8027 (100)
|