Evidence landscape for surgical site infection prevention strategies in low- and middle-income countries: a scoping review of literature for intervention development as part of the IMPRESS study

Objectives Surgical site infections (SSIs) contribute to about 20% of hospital-acquired infections, with an 8–30% incidence in low- and middle-income countries (LMICs). Hospitals in LMIC settings face limited resources, overcrowding, staff shortages and poor infection control. Evaluating effective, feasible and evidence-based multipronged interventions implementable in LMICs is crucial to guide sustainable SSI prevention strategies and improve outcomes. This scoping review addressed the question: “Which SSI prevention interventions have been evaluated in LMICs?” Design The review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR). Data sources The comprehensive literature search was conducted using three databases: PubMed (National Library of Medicine), Scopus (Elsevier) and Embase (Ovid) during August–September 2024. Eligibility criteria Peer-reviewed interventional studies evaluating one or more SSI prevention interventions or intervention bundles were included. Data extraction and synthesis Title and abstract screening was performed by two independent reviewers in Rayaan according to pre-defined inclusion–exclusion criteria, followed by full-text screening from January to March 2025. Data were extracted from the included studies using a standardised Excel sheet, including absolute reductions in SSI rates. Results Of the 8368 studies identified, 5577 remained after de-duplication and underwent title and abstract screening, 245 full-text articles were assessed for full-text review and 186 studies were included in the review. Among the included studies, 101/186 (54.3%) were published between 2020 and 2024, 144/186 (77.4%) were randomised controlled trials and 88 (47.3%) were conducted in India. Overall, 64 SSI prevention interventions were identified, including 13 pre-operative (20.3%), 35 intra-operative (54.7%) and 16 post-operative (25.0%) interventions. The most frequently evaluated interventions were single-dose surgical antimicrobial prophylaxis (SAP) for clean/clean-contaminated surgery (32 studies, 17.2%), post-operative restriction of SAP to <24 hours (22, 11.8%), appropriate antibiotic selection (13, 7%) and timing of SAP within 60 min of surgical incision (12, 6.5%), chlorhexidine skin preparation (11, 5.9%) and WHO Surgical Safety Checklist implementation (10, 5.4%). Across the studies, the most consistent reduction in SSI was observed with guideline-concordant perioperative antimicrobial prophylaxis, alcohol-based chlorhexidine skin preparation, surgeon hand preparation, limiting operating theatre traffic, negative pressure wound therapy, early postoperative bathing, sterile wound care, patient education and SSI surveillance. Conclusions The review suggests that the evidence from LMICs supports optimisation of perioperative antimicrobial therapy alongside implementation of simple, evidence-based infection prevention practices rather than reliance on prolonged post-operative antibiotic use. Developing context-specific SAP policies and strengthening SSI surveillance and staff education are essential for sustainable improvement. There remains a critical need to design and implement multipronged interventions that are scalable and feasible in LMIC settings.