Original Article

A Prospective Study of Surgical Site Infection with its Risk Factors and
Their Correlation with the NNIS Risk Index

Abstract Ravi Meena,

Background: Surgical site infection (SSI) is the third most commonly reported nosocomial infection, Sumit Chakravarti,
accounting for 10%–40% of all nosocomial infections and is a major cause of postoperative morbidity. Suhas Agarwal,
Knowledge of factors related to SSI can help in reducing its incidence and related morbidity, which
in many studies is shown to account for 38% of all infections in surgical patients. Lack of extending
Atul Jain1,
nosocomial infection surveillance programme and prevention measures in countries like India is Shakti Singh,
viewed as a major challenge for the future. Objectives: The aims of this work were (1) to study the Subhajeet Dey
SSI rate in patients undergoing both elective and emergency abdominal surgery and SSI with CDC, Department of Surgery,
and NNIS risk index; and (2) to assess SSI along with body mass index (BMI), glycaemic status, ESI PGIMSR, New Delhi,
smoking and duration of pre-operative hospital stay of patients. Materials and Methods: In total,
1
Department of Surgery,
ABVIMS & Dr. RML Hospital,
300 patients who underwent elective and emergency abdominal surgery were enrolled in the study
New Delhi, India
as per inclusion and exclusion criteria. SSI with CDC’s NNIS risk index were analysed considering
BMI, glycaemic status, smoking and duration of pre-operative hospital stay of patients. Results:
In total, 300 cases of abdominal surgeries (elective and emergency) were analysed, out of which 60
cases were diagnosed to have SSI as per the criteria Conclusion: This study demonstrated that there
is a significant increase in SSI with increasing NNIS score that is, the greater the NNIS score, the
greater the risk of SSI. With an increase in age, BMI, glycaemic index and preoperative hospital
stay, the risk of SSI increases. Smoking and associated comorbidities also increase the risk of SSI.

Keywords: NNIS, risk factors, SSI, surgical site infection, wound discharge

Introduction in social, physical, mental and economic

trauma to patients and their families. Other
Surgical site infection (SSI) is the third most clinical outcomes of SSIs include scars that
reported nosocomial infection, accounting can be hypertrophic or keloids which are
for 10-40% of all nosocomial infections cosmetically unacceptable. These scars can
and is a major cause of postoperative cause persistent pain and itching, restriction
morbidity.[1] It is the commonest and the of movement (particularly when it is over
most troublesome complication of wound joints) and a significant impact on the
healing. emotional state of the patient.
In the United States, an estimated 27 million Surgical practice has seen dramatic changes
surgical procedures are performed each over the past 30 years. It has evolved from
Received: 12-Jan-2023
year.[2] The National Nosocomial Infection Accepted: 30-May-2023
an open procedure to a minimally invasive Published: 16-Sep-2023
Surveillance System (NNIS) established technique. This advancement, coupled with
in 1970, monitors reported trends in the growing attention and advancements in
nosocomial infections in the United the field of hospital infection prevention, Address for correspondence:
State’s acute care hospitals. Based on these which has mainly taken place in countries
Dr. Atul Jain,
reports, SSI accounts for 14% to 16% of all with adequate resources, has led to a
Department of Surgery,
nosocomial infections among hospitalised ABVIMS & Dr. RML Hospital,
significant drop in hospital infections in New Delhi, India.
patients.[3] Indian studies report the rates of those countries with adequate resources. E-mail: [email protected]
SSI to range from 6.1%–25% in abdominal Many countries including India have
surgeries.[4] ineffective hospital infection prevention Access this article online
SSI is responsible for the increase in the programmes due to lack of resources. Only Website:
www.jwacs-jcoac.com
duration of hospital stay, which results few studies have been conducted in these
countries due to limited health budgets.[5] DOI: 10.4103/jwas.jwas_6_23
Quick Response Code:
This is an open access journal, and articles are distributed under
the terms of the Creative Commons Attribution-NonCommercial-
ShareAlike 4.0 License, which allows others to remix, tweak, and
build upon the work non-commercially, as long as appropriate How to cite this article: Meena R, Chakravarti S,
credit is given and the new creations are licensed under the Agarwal S, Jain A, Singh S, Dey S. A prospective
identical terms. study of surgical site infection with its risk factors and
their correlation with the NNIS risk index. J West Afr
Coll Surg 2023;13:26-33.
For reprints contact: [email protected]

26 © 2023 Journal of the West African College of Surgeons | Published by Wolters Kluwer ‑ Medknow
 Meena, et al.: SSI and NNIS risk index

Knowledge of factors related to SSI can help in reducing Exclusion criteria

its incidence and related morbidity, which in many studies
is shown to account for 38% of all infections in surgical • Patients who are already on antibiotic therapy for >1
patients. [6] Implementation of nosocomial infection week.
surveillance programme and prevention measures in countries • Patients undergoing re-operations.
like India is viewed as a major challenge for the future.
Methods for data collection
So, this study was conducted to evaluate the factors associated
with SSI along with its association with NNIS risk factor and Postoperative and management-related factors (type of
risk factor index for SSI surveillance which can be effective procedure, duration of surgery, findings and contamination
in reducing the morbidity due to SSI in the near future. level) were noted in detail. The surgical sites were examined
on the 2nd postoperative day and then daily for pain,
Aims and objective
redness, warmth, swelling and type of discharge (serous/
• To study the SSI rate in patients undergoing both elective purulent). Patient-related factors like BMI, glycaemic
and emergency abdominal surgery and correlate the SSI status, smoking, duration of pre-operative hospital stay of
with CDC’s NNIS risk index. patients and intraoperative surgical findings related factors
• To assess the association of SSI with body mass index were also noted.
(BMI), glycaemic status, smoking and duration of pre- Post-discharge examination of the surgical site was
operative hospital stay of patients. performed for all patients in the out-patient clinic (initially
weekly then monthly basis) for any evidence of SSIs. This
Materials and Methods surveillance was periodically done using the NNIS surgical
surveillance components up to 90 days after discharge in
This prospective observational study was conducted in the
order to detect SSIs that may have appeared after discharge
Department of Surgery, Post Graduate Institute of Medical
(one year in cases of implants).
Sciences and ESI Model Hospital, Basaidarpur, New Delhi
for 2 years. Patients who underwent elective and emergency Sample Size
surgeries and fulfilled the inclusion and exclusion criteria
were enrolled in the study. Using the formula for observational study where Z1-α/2
at 5% type I error is 1.96, P = 25% from previous study,
Definitions
d = 0.05
➣ Surgical site was considered to be infected according to Z1-α /22P(1-P)
the definition by CDC (centre for disease control) and =288
d2
NNIS.
Minimum sample size of 288 patients was required but 300
NNIS parameters patients were enrolled considering the attrition and loss to
follow-up of patients.
Point 0 – For ASA grade 1/ 2, wound class 1/2 and operation
lasting less than T hours Statistical analysis
Point 1 – For ASA grade 3/ 4/5, wound class 3/4 and Statistical analysis was done using the SPSS program for
operation lasting over T hours Windows, version 17.0. Continuous variables were presented
*T hours (75th percentile for the procedure) as mean ± SD, and categorical variables were presented as
absolute numbers and percentage. Data were checked for
NNIS risk index
normality before statistical analysis. Normally distributed
Risk of SSI with Score 0 = 1.5%, Score 1 = 2.9%, Score continuous variables were compared using the unpaired t
2 = 6.8%,Score 3 = 13% test, whereas the Mann–Whitney U test was used for those
variables which were not normally distributed. Categorical
➣ The wounds were classified according to the wound
variables were analysed using both the chi-square test and
contamination class system.
Fisher’s exact test. For all statistical tests, a P value less than
(Class 1 – Clean, Class 2 – Clean-Contaminated, Class 3 – 0.005 was considered statistically significant.
Contaminated, and Class 4 – Dirty-Infected)
Results
Inclusion criteria
A total of 300 cases of abdominal surgeries (elective and
• All patients undergoing elective and emergency emergency both) were analysed, out of which 60 cases were
abdominal surgeries. diagnosed to have SSI as per the criteria, and following
• Age >18 years observations were made.

Journal of the West African College of Surgeons | Volume 13 | Issue 4 | October-December 2023 27
 Meena, et al.: SSI and NNIS risk index

Incidence of SSI Type of abdominal surgical procedure

In our study, the incidence of SSI in abdominal surgeries In this study different abdominal surgeries were included
(elective and emergency) was 20%. as mentioned in Table 3.
SSI in different age groups Incidence of SSI among elective and emergency surgery

The total study population was 300 cases (n = 300). The The total number of patients who underwent elective
following observations were made among different age surgery was 216 (72%) out of which 34 (15.74%) patients
groups [Table 1].
developed SSI. while the total number of patients who
Total number of patients below 40 years was 153, out of underwent emergency surgery was 84 (28%) out of which
which 24 patients had SSI (16%), while patients above 40 26 (30.95%) patients developed SSI [Table 4]. P value was
numbered 147, out of which 36 patients had SSI (24%). significant that is, <0.0001.
There was a gradual rise in SSI with advancing age. Effect of BMI on SSI
Gender correlation
A higher incidence of SSI (22.22%) was noted in overweight
In females, 20.97% developed SSI as compared to 19.32% in and obese patients (100%) as compared to normal BMI
male patients. The P value was 0.016 which is insignificant patients (17.42%). P value was significant that is, 0.0002
statistically [Table 2]. [Table 5].

Table 1: Incidence of SSI among different age groups

Age group (years) SSI No infection Total
Superficial Deep
≤ 20 years 0(0%) 2(14.29%) 12(85.71%) 14(100%)
21-30 years 1(1.67%) 8(13.33%) 51(85%) 60(100%)
31-40 years 5(6.33%) 8(10.13%) 66(83.54%) 79(100%)
41-50 years 11(18.03%) 6(9.84%) 44(72.13%) 61(100%)
51-60 years 8(16.67%) 3(6.25%) 37(77.08%) 48(100%)
61-70 years 4(11.76%) 3(8.82%) 27(79.41%) 34(100%)
>70 years (0%) 1(25%) 3(75%) 4(100%)
Total 29(9.67%) 31(10.33%) 240(80%) 300 (100%)

Table 2: Co relation between gender and SSI

Gender SSI No infection Total P value
Superficial Deep
Male 11(6.25%) 23(13.07%) 142(80.68%) 176(100%) 0.016
Female 18(14.52%) 8(6.45%) 98(79.03%) 124(100%)
Total 29(9.67%) 31(10.33%) 240(80%) 300 (100%)

Table 3: Type of abdominal surgical procedure

S.NO Surgical procedure done Number of surgeries Percentage (N = 300)
1 Open Cholecystectomy 75 25%
2 Abdominal Perineal Resection 3 1%
3 Cystolithotomy 3 1%
4 Distal Gastrectomy 2 0.67%
5 Exploratory Laparotomy 29 9.67%
6 Feeding Jejunostomy 1 0.33%
7 Stoma Closure 3 1%
8 Lap Converted Open Cholecystectomy 6 2%
9 Nephrectomy 7 2.33%
10 Open Appendectomy 47 15.67%
11 Open Chole + Open Mesh Hernioplasty 2 0.33%
12 Open Mesh Hernioplasty 120 40.33%
13 Partial Cholecystectomy + Gastrojejunostomy+Resection Anastomosis 1 0.33%
14 Excision 1 0.33%

28 Journal of the West African College of Surgeons | Volume 13 | Issue 4 | October-December 2023
 Meena, et al.: SSI and NNIS risk index

Table 4: Incidence of ssi among elective and emergency surgery

Procedure SSI No infection Total P value
Superficial Deep
Elective 26(12.04%) 8(3.7%) 182(84.26%) 216(100%) <0.0001
Emergency 3(3.57%) 23(27.38%) 58(69.05%) 84(100%)
Total 29(9.67%) 31(10.33%) 240(80%) 300 (100%)

Table 5: Co relation between BMI and SSI

BMI SSI No Infection Total P value
Superficial Deep
Normal 8(5.16%) 19(12.26%) 128(82.58%) 155(100%) 0.0002
Overweight 20(13.89%) 12(8.33%) 112(77.78%) 144(100%)
Obese 1(100%) 0(0%) 0(0%) 1(100%)
Total 29(9.67%) 31(10.33%) 240(80%) 300 (100%)

Graph 1: Correlation between smoking and SSI Graph 2: Correlation between glycaemic status and SSI

Effect of smoking on SSI

days pre-operatively was 118 (39.33%), while a stay of three
days pre-operatively was noted in 95 (31.66%) patients. Two
On analysis it was found that SSI (26.31%) was more
patients had a 5- and 6-day pre-operative stay [Graph 3].
common in smokers as compared to non-smokers. P value
was significant that is, <0.0001 [Graph 1]. SSI rate significantly increased with increasing in
pre-operative stay as P value is significant which is
Effect of glycaemic status on SSI <0.0001[Graph 3].
For HbA1c < 6, SSI was 16.59% (non-diabetic patients) Significance of NNIS score in SSI
For HbA1c 6-7.5, SSI was 27.59% (diabetic patients) For NNIS score 0, SSI rate was 10.04% (22 SSI in 219
For HbA1c > 7.5, SSI was 25% (uncontrolled diabetes patients), while for NNIS score 1, SSI rate was 46.83% (37
mellitus) SSI in 79 patients). Moreover, 50% SSI rate was noted in
patients with NNIS score 2 (1 SSI in 2 patients), showing
Above data shows that the rate of SSI increases with that the rate of SSI increased with NNIS score. P value is
increasing value of HbA1c. P value < 0.0001 which is significant (<0.0001) [Table 6].
significant [Graph 2].
Effect of comorbidity on SSI
Effect of pre-operative stay on SSI
Total number of comorbid patients were 53 (17.66%) while
Patients operated on the same day (emergency cases) were 247 (82.33%) patients did not have any comorbidity. SSI
88 (29.33%), and the number of patients who stayed for two rate (32.08%) was higher in comorbid patients as compared

Journal of the West African College of Surgeons | Volume 13 | Issue 4 | October-December 2023 29
 Meena, et al.: SSI and NNIS risk index

to SSI (17.41%) in non-comorbid patients. P value is from the day of operation, to 90 days after discharge and
significant (<0.0001). one year in case of implants.
Wound class and SSI Rate of surgical site infection
In 233 patients with class 1 wound (clean), SSI rate The SSI rate for 300 cases in present study was 20%.
was 14.59%.
Different studies from India has shown the SSI rate to
In 30 patients with class 2 wound (clean-contaminated), vary from 6.09% to 38.7%.[6] The infection rate in Indian
SSI rate was 10%. hospitals is much higher than that in other countries; for
instance in the USA, it is 2%–5%.[7]
In 30 patients with class 3 wound (contaminated), SSI rate
was 53.33%. The higher infection rate in Indian Government hospitals
may be attributed to high patient load, lower socioeconomic
And in 7 patients with class 4 wound (dirty), a 100% SSI
status of patients in general surgery setting and lack of
rate was noted.
attention towards the basic infection control measures and
SSI rate increased significantly with increase in class of the basic hygiene. Table 7 shows incidence in various other
wound (P value= <0.0001) [Graph 4]. study settings.[6,8-12]
Pattern of microorganism growth Effect of age on SSI
Staphylococcus aureus was the most common organism The SSI showed a gradual rise from 16% in below 40 years
which was isolated in 21 patients (35%). The second most to 24% in above 40 years age group. There was a significant
common was E. coli, which was isolated in 15 patients (25%), increase in SSI with an increase in age, which was similar
followed by Klebsiella in 9 patients (15%), pseudomonas in to results in a study by Rajanikanth et al.[13]
8 patients (13.33%), enterococcus in 5 patients (8.3%) and
Similar findings were demonstrated by Sattar et al.[14] who
Acinetobactor in 2 patients (3.33%).
observed that SSI rates were highest in the age group above
Discussion
This was a prospective study of 300 cases that had undergone
abdominal surgery in our hospital, and were followed up

Graph 3: Correlation between preop stay and SSI Graph 4: Correlation between wound class and SSI

Table 6: Co relation between nnis and SSI

NNIS SCORE SSI No infection Total P value
Superficial Deep
0 14(6.39%) 8(3.65%) 197(89.95%) 219(100%) <0.0001 HS
1 14(17.72%) 23(29.11%) 42(53.16%) 79(100%)
2 1(50%) 0(0%) 1(50%) 2(100%)
Total 29(9.67%) 31(10.33%) 240(80%) 300 (100%)

30 Journal of the West African College of Surgeons | Volume 13 | Issue 4 | October-December 2023
 Meena, et al.: SSI and NNIS risk index

Table 7: Rate of SSI in different studies

Author Number of Surgeries Year Country Infection
Cruse and Foord[8] 62939 1980 Canada 4.7%
Anvikar et al.[9] 3280 1999 India 6.09%
Umesh et al.[10] 114 2008 India 30.7%
Mahesh C B et al.[6] 418 2010 India 20.9%
Siddalinga et al.[11] 100 2011 India 15%
Mekhla et al.[12] 169 2019 India 39%
Present study 300 2020 India 20%

55 years (36.4%). High SSI rates in older age groups are Smoking and SSI
due to co-morbid conditions and poor immune response.[15]
In this study, patients who were smokers were more
The high SSI rate in older persons in our study may thus
predisposed to develop SSI when compared to non-
be due to the aforementioned reasons.
smokers (SSI rate = 26.31% in smokers and 14.97% in
Gender distribution and SSI non-smokers). Similar results were found by Huquan
et al.[20] (smoker = 5.4% and non-smoker = 4.2%) in 2019.
In this study, SSI was noted more in female patients
Glycaemic index
(20.97%) in comparison to male patients (19.32%). Our
results are in concordance with results shown in a study
In this study, it was seen that patients with poorly controlled
by Adeyinka et al.[16]
blood glucose levels had higher SSI rate in comparison to
In our literature review, no clear consensus could be drawn. patients having good control over blood glucose levels.
Some studies have shown that male patients have a higher Patients who had HbA1c level <6 SSI rate were 16.59%,
incidence of SSI than female patients while in others, female whereas in patients with HbA1c level between 6 and 7.5
patients had a higher incidence of SSI.[16,17] SSI rate was 27.59% and patients with HbA1c more than
7.5, SSI rate was 25%. To prevent SSI in DM patients,
SSI in emergency vs. elective surgery
we recommend lowering the HbA1c to <7.0% before
surgery.[21]
The SSI rate in elective surgeries was found to be 15.74%
which increased to 30.95% in emergency cases. Similar In a study by Mishra et al.[22] they found that even in non-
results were found by Kumar et al.,[18] in which 17.7% of diabetic patients when there is stress-induced perioperative
SSI was associated with emergency surgeries and 12.5% of hyperglycaemia, the rate of SSI was more as compared to
SSI with elective surgeries. patient with normal blood sugar levels.
The higher rate in emergency surgeries can be multifactorial; Pre-operative stay
lack of preoperative preparation, debilitated condition
of patient, underlying infective pathologies and more Prolonged preoperative hospital stay was the independent
frequency of contaminated and dirty wounds in emergency predictor of SSI.[23] Mundhada et al.[24] found that patients
surgeries. who had a preoperative stay of more than 1 week were more
associated with SSI (43%).
In elective surgeries the patients are generally well nourished
and have adequate time for preoperative preparation and Similar results were seen in this study, where patients who
optimisation of unfavourable factors. This helps in better were operated within two days, had lower (7.61%) SSI rate
outcome of these patients; however, SSI can happen owing in comparison to patients with pre-operative stay more
to the underlying pathology or intraoperative factors also. than 2 days (27.6%).
BMI and SSI NNIS risk index

In this study, patients who had a high BMI were associated The work of Haley et al.[25] investigators at the Centre for
with a high incidence of SSI. In patients with normal Disease Control and Prevention (CDC), reported on a
BMI, SSI incidence was lower (17.42%) in comparison to composite risk index used in the National Nosocomial
overweight patients (22.22%) and obese patients (100%). Infections Surveillance (NNIS System).
Similar results were found by Naveen et al.[19]
In our study it was found that SSI rate is 10.04% for NNIS
Obesity increased the risk of SSI nearly fourfold among score 0, 46.83% for NNIS score 1 and 50% for NNIS score
patients who underwent operations in the United Kingdom 2. Hence, SSI rate increases with an increase in NNIS score.
from 2006 to 2010.[17] Overall, the SSI risk increased with Similar results were found in study done by Patel[26] (NNIS
increasing BMI. 0 = 0%, NNIS 1 = 15.7%, NNIS 2 = 52.5%) in 2011.

Journal of the West African College of Surgeons | Volume 13 | Issue 4 | October-December 2023 31
 Meena, et al.: SSI and NNIS risk index

Co-morbidities 3. Klevens M, Edwards JR, Richards CL, Jr, Horan TC, Gaynes RP,
Pollock DA, et al. Estimating health care associated infections
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160-6.
frequent comorbidities associated with surgical wound
4. Lilani SP, Jangale N, Chowdhary A, Daver GB. Surgical infection
infection reported worldwide.
in clean and clean contaminated cases. Indian J Med Microbiol
In a study by Mejía et al.,[27] a higher incidence of SSI was 2005;23:249-52.
found in patients suffering from diabetes mellitus (25.3%) 5. Ponce-de-Leon S. The needs of developing countries and the
resources required. J Hosp Infect 1991;18:376-81.
and patients of low immunity group (43.4%). In our study,
6. Mahesh CB, Shivakumar S, Suresh BS, Chidanand SP,
we found that SSI rate (32.08%) was much higher in
Vishwanath Y. A prospective study of surgical site infections
comorbid patients as compared to non-co-morbid patients in a teaching hospital. J Clin Diagn Res 2010;4:3114-9.
in which the SSI rate was 17.41%. 7. Ban KA, Minei JP, Laronga C, Harbrecht BG, Jensen EH,
Wound class Fry DE, et al. American College of Surgeons and Surgical
Infection Society: surgical site infection guidelines, 2016
update. J Am Coll Surg 2017;224:59-74. doi:10.1016/j.
In our study, we found that the SSI rate increases with jamcollsurg.2016.10.029.
increased contamination of the wound (dirty > clean). 8. Cruse PJ, Foord R. The epidemiology of wound infection. A 10-
Similar result was found by Mekhla et al., in which clean and
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1980;60:27-40.
clean-contaminated wounds had an SSI rate of 23.7% and dirty
9. Anvikar AR, Deshmukh AB, Karyakarte RP, Damle AS,
wounds had an SSI rate of 60.9%. SSI rate in contaminated and Patwardhan NS, Malik AK, et al. A one year prospective study
dirty cases were significantly higher (RR 2.57, CI 1.52–4.31). of 3,280 surgical wounds. Indian J Med Microbiol 1999;17:
SSI is higher in class 3 and 4 wounds because of the spillage of 129-32.
10. Kamat US, Fereirra AMA, Kulkarni MS, Motghare DD. A
GI tract contents in peritoneal cavity, acute inflammation in
prospective study of surgical site infections in a teaching hospital
the tissues with or without purulent collection encountered in Goa. Indian J Surg 2008;70:120-4.
intraoperatively and delayed presentation increases the 11. Siddalinga Swamy P M, Abdominal Surgical Site Infection
contamination and devitalised tissues. Incidence And Risk Factors. Karnataka, Bangalore: Rajiv
Gandhi University of Health Sciences; 2011.
Conclusion 12. Mekhla, Borle FR. Determinants of superficial SSIs in
abdominal surgeries at a Rural Teaching Hospital in Central
This study demonstrated that there is a significant increase
India: A prospective study. J Family Med Prim Care [serial online]
in SSI with increasing NNIS score. With the increase in 2019;8:2258-63.
age, BMI, glycaemic index and preoperative hospital stay, 13. Amrutham R, Reddy MMB, Pyadala N. A prospective study
the risk of SSI increases. Smoking and other comorbidities of surgical site infections and related risk factors in a teaching
also increase the risk of SSI. hospital. Int Surg J 2017;4:237-41.
14. Sattar F, Sattar Z, Zaman M, Akbar S. Frequency of Post-
Certain contributing factors to SSI can be rectified which can operative Surgical Site Infections in a Tertiary Care Hospital in
prevent or decrease the incidence of SSI. The optimisation Abbottabad, Pakistan. Cureus 2019;11:e4243.
of the patient before surgery is desired in cases planned for 15. Ashby E, Davis MJ, Wilson AP, Haddad FS. Age, ASA and
elective surgery and in case of emergency surgeries, proper BMI as risk factors for surgical site infection measured using
resuscitation should be done to improve the outcome and ASEPSIS in trauma and orthopaedic surgery. J Bone Joint Surg
prevent SSI. Br 2012;94:58.
16. Adejumo AA, Nuhu M, Afolaranmi T. Incidence of and risk
In this study, it was found that the scoring of this index factors for abdominal surgical site infection in a Nigerian tertiary
accurately assessed the risk and therefore we recommend the care centre. Int J Infect Control 2015;11:4.
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Financial support and sponsorship risk factors, and clinical and economic burdens. Surg Infect
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Conflicts of interest surgery in a tertiary care centre in India. IntSurg J 2017;4:3101-6.
19. Kikkeri N, Setty H, Nagaraja MS, Nagappa DH, Giriyaiah CS,
There are no conflicts of interest.
Gowda NR, et al. A study on surgical site infections and
associated factors in a government tertiary care teaching hospital
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