The Incidence of Early Surgical Site Infections in patients undergoing Open Reduction Internal Fixation of femur shaft fractures in KNH Dr Awadh Hemed, MB.ChB., Mmed Ortho (U.o.N) MULIMBA J.A.O MOGIRE T.

INTRODUCTION Semmelweis and Lister pioneered infection control by introducing anti-septic surgery. Prior to this, open fractures, especially those that had deep infections were associated with mortality rates as high as 70 – 80%. The current trend for the management of femur fractures is Closed Reduction Internal Fixation in many set ups in Kenya is Open Reduction Internal Fixation (ORIF).

ORIF is associated with a higher risk of Surgical Site Infection compared to Closed Reduction Despite improvement in infection control practices, surgical site infections (SSI) still pose significant risk in any surgical procedure. Notably, extra burden on healthcare as a whole in terms of increased morbidity and mortality.

OBJECTIVES Primary Objective To determine the incidence of early surgical site infections in patients undergoing ORIF for closed femoral shaft fractures in KNH.

Secondary Objectives 1. To determine the pre-operative length of stay, 2. To determine the duration of surgery, and 3.To determine the post-operative length of stay in patients who undergo ORIF for closed femur shaft fractures in KNH and their influence on SSI.

METHODOLOGY This was a prospective cohort study. carried out in the orthopaedic wards, main theatre and clinic 5 (orthopaedic and trauma clinic) at the Kenyatta National Hospital. Study period was from 1st July 2014 to 30th September 2014.

Exclusion Criteria 1) Below 18 years of age 2) Pathological fractures. 3) Open fractures or wounds in the vicinity of the fracture Sample size was calculated using Fischer’s formula for prevalence studies. the final sample size was 77 Ethical approval by University of Nairobi and The Kenyatta National Hospital-University of Nairobi Ethical Review Committee (KNH-UON ERC).

The CDC criteria for SSI was applied in determining the presence of SSI

OUTCOMES Of the 77 PATIENTS who underwent ORIF for closed fractures shaft femur, 13 patients developed SSI, therefore an overall incidence of SSI of 16.88%. when we control for confounding factors of SSI we find that all the factors have NO statistically significant effect on SSI except DIABETES MELITUS (p=0.025) and PRE-OPERATIVE LENGTH OF STAY

DISCUSSION An overall incidence of SSI of 16.9% was found in this study. This is far higher than reported SSI incidence of between 5-7% in Western literature. In Eastern Europe, A prospective study done by Maksimovic et al [50] over a 6 month period in Belgrade, Serbia in 2002, found an incidence rate of SSI in orthopaedic patients to be 22.7%.

In Tanzania, Eriksen et al found an overall incidence rate at The Kilimanjaro Medical Centre in 2003, to be 19.4% in Ethiopia, in a study by Kotiso B et al in 1998, found the SSI incidence rate to be 21% based on clinical criteria.

LIMITATIONS 1.This study had a small sample size 2.The study period was short 3.A bacteriological study was not done. 4.The Period of follow up with implants in situ was short.

RECOMMENDATIONS prompt referrals patients with fractures should first be taken for ORIF directly from casualty before admission to the ward. Use of closed methods of fracture fixation. Tight glycemic control A surveillance program can be put in place to monitor infection control. A larger study, of longer duration and which will include bacteriological studies as well as antibiotic sensitivity patterns