Epidemiology and risk factors of surgical site infections in elective surgeries in Pakistan (2022–2023): a multicentre, prospective cohort study from PakSurg 1

Summary Background Surgical site infections (SSIs) are a leading and preventable cause of postoperative morbidity in Pakistan. However, the absence of national-level data has precluded the development of targeted preventative measures. PakSurg1 aimed to quantify the burden of SSIs and evaluate associated risk factors in a multicentre cohort across Pakistan. Methods We conducted a prospective cohort study of 1711 patients across 28 hospitals in Pakistan from 2022 to 2023. Adult patients undergoing elective general or subspecialty surgery were followed for 30 days postoperatively. We assessed SSI incidence and identified risk factors at the patient, surgical, and hospital levels. Findings The overall incidence of SSIs was 9.5% (n = 163). Most SSIs were superficial (73.6%; n=120) and managed non-surgically with antibiotics (66.9%; n=109). On multivariable analysis, SSIs were more likely in patients undergoing trauma-related surgery (OR: 3.047 [95% CI: 1.205–7.708]), with contaminated or dirty wounds (OR: 3.245 [95% CI: 1.298–8.113]), or with longer hospital stays (OR: 1.068 [95% CI: 1.036–1.101]). Several modifiable factors were associated with lower odds of SSI. These included laparoscopic surgery (OR: 0.556 [95% CI: 0.343–0.900]), ambulatory procedures (OR: 0.598 [95% CI: 0.375–0.953]), combined chlorhexidine and povidone-iodine skin preparation (OR: 0.304 [95% CI: 0.131–0.704]), and completion of a surgical time-out (OR: 0.446 [95% CI: 0.268–0.743]). Compared to general surgery, lower SSI odds were observed in cardiac (OR: 0.223 [95% CI: 0.074–0.672]), cranio-spinal (OR: 0.292 [95% CI: 0.126–0.676]), and orthopaedic (OR: 0.216 [95% CI: 0.071–0.655]) procedures. Interpretation PakSurg 1 provides a national estimate of SSI incidence in elective surgeries in Pakistan and identifies key, modifiable risk factors. These findings can inform targeted, context-specific strategies to reduce SSIs and improve surgical safety nationwide. Funding This study received monetary funding from the Student & Trainee Initiated Research Program (MBBS Class of '88 Awards, Aga Khan University, Karachi, Pakistan).