A study of Microorganisms causing wound infections after Elective laparotomy

Sofia Noor1, Akash John2, Taimoor Hassan3, Aasia Noor 4, Amina Noor1, Neelam Iqbal5 and Tallat Anwar Faridi1* 1University Institute of Public Health, The University of Lahore, Lahore, Pakistan 2University Institute of Radiological and Medical Imaging Sciences, The University of Lahore, Gujrat Campus, Pakistan 3Department of Professional Health Technologies, The University of Lahore, Lahore, Pakistan 4 Services Institute of Medical Sciences, Lahore, Pakistan 5Institute of Molecular Biology and Biotechnology, The University of Lahore, Lahore

Any purulent discharge from a closed surgical incision, after surgery, together with signs of inflammation of the surrounding tissue should be considered as Post operative (post-op) wound infection. There are two types of wounds in elective laparotomy: clean and contaminated wound Objective: To find out most causative microorganism involved in post-op wound infection in elective laparotomy cases at the Children Hospital and The Institute of Child Health Sciences, Lahore Pakistan. Methods: It was a prospective observational study conducted on patients who developed wound infection after elective laparotomy. This study was conducted in the surgical Units I and II of Children Hospital Lahore, Lahore, Pakistan. The duration of the study was 11 months from January 2019 to November 2019. 150 patients were included in this study. Data was collected by convenient sampling technique. It was a hospital-based study in which patients from both genders were included. Data was obtained by a questionnaire. Patients were asked for wound condition and surgery details were taken to find out the reasons of wound infection. The data selected was analyzed using SPSS version 21.0. Results: Out of total 150 patients who underwent elective laparotomy, 40% patients were identified with Escherichia Coli, 13.3% patients identified with Pseudomonas species, 13.3% patients had klebsiella, 6.7% patients had Pseudomonas Florescence, 6.7% people had Acinetobacter, 6.7% had Staphylococcus aureus, 13.3% did not show any growth. Conclusions: It was concluded that most abundant microorganism isolated from patients who underwent elective laparotomy was Escherichia coli. The most common reasons for wound infection were increase in number of surgeons and increase in duration of illness.  [10]. The best way of diagnosis of microorganisms involved in wound contamination at the end of an operation and the risk of developing infection is to take pus sample for culture and sensitivity [8]. Theoretical degree of contamination relates well to infection rates. Heavily contaminated wounds are at higher risk [11]. Prophylactic antibiotic reduces the potential of infection. From National Nosocomial Infection Surveillance System (USA), It is revealed that most common pathogens for SSI (surgical site infection) are Staphylococcus aureus [12], Enterococcus especially coagulase negative staphylococcus, Enterobacteriaceae, Pseudomonas specially and anaerobes [13].

I N T R O D U C T I O N
Laparotomy is a surgical procedure involving a large incision through the abdominal wall to [14] gain access into the abdominal cavity. There are two types of laparotomy. Elective laparotomy is done when surgery is pre planned. It is done when there is tumor, liver enlargement, liver cirrhosis, blockage in urinary tract, spleen enlargement, endometriosis, ectopic pregnancy, inflammation of pancreas, appendicitis, damage to any organ and any gut problem. Other general reasons are infection such as old abscess, tumor and adhesions in inflammation. There are further two types of Elective Laparotomy [15], Clean Elective Laparotomy, in which we open abdomen but gut is not involved, Clean Contaminated, [16] in which we also open gut.
Complications of elective laparotomy are [17] fever, pain, hemorrhage, wound infection, blood clotting, damage to organ, large scar, reaction to anesthesia, nausea, vomiting and incisional hernia. Some factors that increase the risk of post op complications are previous abdominal surgery, diabetes, heart or lung disease, weak immune system, blood factors, smoking and alcohol abuse etc. [18]. Surgeries

Cases of Wound infection after Elective
Laparotomy were included in our study, rest all the cases were in the exclusion criterion. The confidentiality was maintained during the whole process of research. Ethical approval was taken from the IRB (Institutional Review Board) of the parent teaching institute. Data is presented in tables analyzed by using Statistical Package for the Social Sciences (SPSS) software computer program version 21.0.
R e s u l t s Table 1 shows that 38.3% people with less than age 5 years were detected with E. coli in their wound, while 61.6% of E. coli was detected in the people whose age were between 5-10 years old, Furthermore, we did not detect any E. coli presence in the people whose age were greater than 10 years old.

Age in Years
E. Coli    Table 3 shows that after performing the Elective Laparotomy, 100% patient's experienced wound infection. 40% people were diagnosed with fever while 26.7% did not and 33.3% felt fever off and on. 100% people experienced Discharge from drain. 100% people showed redness, 100% people showed Swelling. Table 4 shows that from a population of 100%, 40% people were detected with E.coli in their Wound infection after Elective Laparotomy, 13.3% people were detected with Pseudomonas, 13.3% people detected with klebsiella pathogen, 6.7% people were identified with Pseudomonas fluorescence, 6.7% people were detected with Acinetobacter, 6.7% people were identified with Staphylococcus aureus, 13.7% people did not show any bacterial growth.

D i s c u s s i o n
The current study is conducted to find out the prevalence of causative microorganisms involved in wound infection after Elective laparotomy and data is collected from the surgical ward of Children Hospital and The Institute of Child Health, Lahore. In the present study 150 infected patients were selected undergoing elective laparotomy and it is concluded that (40%) of the patients had causative microorganism E. coli followed by (13.3%) of the patients with klebsiella. The similar study on elective laparotomy was conducted by a group of researchers in United States of American, the sample size consisted of 300 patients, it was also a hospital-based study, [20]and they found that the most abundant microorganisms isolated were E. coli and Klebsiella among other pathogens.
A study of laparotomy wound infection had done in M.G.M Hospital, Navi Mumbai. Total 75 had taken from surgical wards and studied prospectively. The study included both elective & emergency laparotomies. This study shows the presence of E. coli (50%) [21] and other microorganisms in wound infection after laparotomy. Another study was done on 200 patients who underwent elective and emergency laparotomy. Discharge from all wounds was subjected to microbiological analysis. The incidence of SSI following laparotomies was 25% [22]. Risk factors being emergency laparotomy, dirty wound, male sex, increased age, smoking, diabetes mellitus, obesity, hemoglobin < 10 gm %, albumin < 3gm/dl, duration of surgery > 2hrs. Most common organism isolated was E. coli. A Prospective study was done on 100 patients. Swabs from Subcutaneous tissue were collected after closing the fascia of abdomen during their colon surgery. From 100 swabs, 52 were marked as sterile with no specific wound infection, while 10 swabs were considered as dirty, causing wound infection by the colonic microorganisms/pathogens and nosocomial microorganisms. From the 100 swabs, 52 swabs did not show any growth, out of remaining 48, 21 showed aerobic bacterial growth, 13 showed anaerobic bacterial growth, 14 showed a complex of anaerobic and aerobic bacteria. The results concluded that in the growth of Aerobic bacteria, Escherichia Coli was the most common to be found in 18 swabs, Streptococcus spp. were found PBMJ Vol.4 Issue 2 Jul-Dec 2021 Noor S et al., in 8 swabs. While in Anaerobic growth, Bacteroides fragilis was found in 17 swabs [23].
In this study, the samples of patients with infected wound discharge were delivered for cultural sensitivity tests, the results pinpointed that after observing all the sterile techniques applied for prevention of wound infection, the incidence of superficial infection was quite lower, the results concluded that E. coli was the most common pathogen to be found in the wounds of patients. A study conducted on patients who undergone Laparotomy surgeries (Emergency & Elective) in India. A sum of 400 cases were studied in this prospective study, while mentioning about the incidence of SSI, it was 9.75%. The elective cases had an incidence of 5% while emergency had 24%. Many cases detected SSI on their 3 rd Post-operative day. The rates of infection gone up from clean to contaminated wounds. It was found out that E. coli was the popular pathogen to be present.

C o n c l u s i o n s
It is concluded that rate of microorganisms and wound infection increased with the increase in the duration of surgery, because the exposure of wound with the environment increases that results in wound infection and ultimately growth of microorganisms. The most common reasons of wound infection in elective laparotomy were increase in duration of surgery and number of surgeons involved in surgery and it was concluded that most abundant microorganism isolated was E. coli.