The Impact of Surgical Site Infection on Health-related Quality of Life: A Systematic Review

Surgical site infection (SSI) is a common type of health care–acquired infection.¹ It can vary in severity from superficial, involving the skin only, to more serious infections involving deeper tissue, organs, or implanted material.² SSI rates vary depending on the type of surgery and on the degree of contamination; 11% of patients who undergo surgery experience an SSI.³ The cumulative incidence of patients with SSI was the highest in colon surgery at 9.5% (episodes per 100 operations), and the lowest rate was 0.75% for knee prosthesis.³ According to the annual epidemiological report by the European Centre for Disease Prevention and Control,⁴ the incidence of SSIs varies from 0.5% (keratoprosthetics surgery) to 10.1% (colon surgery).

Surgical site infections are the most common cause of physical and mental health discomfort, resulting in longer inpatient stays, higher costs to the health care system, and increased mortality rates.^5-7 Patients may experience delayed wound healing, resulting in an increased vulnerability to secondary complications such as bacteremia, tissue necrosis, and periwound edema.^8,9 Surgical site infections also constitute a financial burden. A systematic review by Badia et al⁸ of 26 studies conducted in 6 European countries that assessed and evaluated the cost and health-related quality of life (QoL) burden of SSIs found that the cost per day of hospitalization for SSI rose from €350 to €1140; expenditures were attributed to investigative and treatment costs, operative costs, and medical staff costs.

The literature suggests that several risk factors contribute to the development of SSI. According to the expert panel perspective by Tartari et al,¹⁰ a systematic review and meta-analysis by Schweizer et al,¹¹ and a retrospective report by Ansari et al,¹² use of specific SSI care bundles and surgical safety checklists has been shown to have a positive impact on reducing SSI incidence.

Consideration of the patient experience is part of the goal to deliver humane and empathetic care.¹³ Thus, a greater understanding of the SSI experience and its impact on QoL and overall recovery should be required when crafting solutions for health care challenges such as SSI. Moreover, feedback from patients about their experiences can provide valuable insights into how care is provided.

Despite the existing extensive research on this topic to date, no systematic review has been undertaken on the impact of SSI on patient QoL. The current systematic review aimed to provide an in-depth understanding of the lived experience and QoL of individuals with SSI by examining the literature regarding the impact of SSI as evaluated by health-related QoL measures and by exploring the lived experience of patients with SSIs.

The specific research question was, “What is the impact of SSI on the individual’s QoL?” The primary outcome of this systematic review was QoL scores with regard to SSI through exploration of the lived experience of SSI. Secondarily, this review sought to elucidate the use of a QoL measurement tool employed within the studies.

Inclusion and exclusion criteria. The literature search included published studies that explored the impact of SSI on QoL among adult patients (older than 18 years) with existing SSI and history of SSI who had undergone any type of surgery. All quantitative and qualitative study designs were included; no setting, language, or date of publication restrictions were applied.

Databases and search terms. The literature search was conducted by 2 reviewers (ZM and PA) from June 2 to June 26, 2020. The following electronic databases were searched to identify relevant literature: Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library) (most recent issue), Ovid MEDLINE (1946 to June 2020), Ovid MEDLINE (in process and other nonindexed citations; latest issue), Ovid Embase (1974 to June 2020), EBSCO Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus (1937 to June 2020), and Scopus. The search terms applied included “surgical site infection” OR “hospital-acquired infection” OR “nosocomial infection” OR “wound site infection” OR “surgical wound site infection” AND “Quality of Life” OR “Life quality” OR “Health-Related Quality of Life” OR “Life Style” OR “QOL” OR “HRQoL” OR “Short-form questionnaire 36” OR “Questionnaire SF-36” OR “SF-36.”

The following clinical trial registries were also searched to identify unpublished and ongoing studies: World Health Organization International Clinical Trials Registry Platform (www.who.int/trialsearch), the International Standard Randomised Controlled Trial Number registry (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov), European Union Clinical Trials Register (www.clinicaltrialsregister.eu), and DART-Europe (https://www.dart-europe.org/basic-search.php). Additionally, the research team scanned the reference lists of all identified studies and reviews and searched grey literature using Open Grey (www.opengrey.eu) for published, unpublished, and ongoing studies.

Study selection. Article titles were assessed by 2 authors independently (ZM and PA), and the abstracts (when available) of the studies identified by the search strategy were screened for their eligibility according to the inclusion and exclusion criteria. The full-text versions of potentially relevant studies were obtained and screened by the same 2 authors independently against the inclusion criteria. Consensus between the 2 authors in relation to the studies and the data to be included was obtained through a discussion when discrepancies were identified.

Data extraction. Data extracted from the retrieved articles were collected in a spreadsheet and included study author, date, setting, sample size, population, and design as well as type of surgery. Publication/study quality was assessed using the Critical Appraisal Skills Program (CASP) Qualitative Checklist. The CASP tool is a generic tool for appraising the strengths and limitations of any qualitative research methodology. The tool has 10 questions that each focus on a different methodological aspect of a qualitative study.¹⁴

Data analysis of included study data. Because the data extraction revealed heterogeneity of the included studies in terms of QoL measurement tools, a meta-analysis (statistical synthesis) was considered inappropriate. Thus, the data first were narratively summarized to develop an overview of the study setting, geographical location, sample sizes, QoL instrument, and outcomes. This was followed by quality appraisal, structured narrative synthesis of the quantitative studies, and a narrative thematic synthesis of the qualitative studies. The CASP was utilized, adapting 2 questions, to assess and compare all eligible studies with diverse methodologies. The question, “Is a qualitative methodology appropriate?” was changed to, “Is a qualitative/quantitative methodology appropriate?” For quantitative studies, the question, “Was the data analysis sufficiently rigorous?” was changed to “Was the data analysis sufficiently rigorous in terms of the size of the confidence intervals and by examining whether confounding factors, blinding of providers, and response rate?” Studies that obtained negative ratings for at least 5 of 10 items (ie, “no,” “can’t tell,” or “unclear”) were excluded from this review.

Quantitative data tools. Quantitative data included results of the Short Form-36 (SF-36),¹⁵ the Surgical Wound Infection (SWI) questionnaire,¹⁶ and the Health-related Quality of Life instrument (HRQoL).⁶

The SF-36 is a generic, self-administered general health status survey comprising 36 items that measure physical functioning, physical role limitations, bodily pain, vitality, general health, social functioning, emotional role limitations, and mental health. The scores for each dimension are summed for a total score of 0 to 100; higher scores indicate better health quality.¹⁵

The SWI questionnaire was designed by Jidéus et al¹⁶ to measure morbidity due to sternum-related problems after surgery and to provide a description of the present status of the sternum. The SWI questionnaire contains 11 items for self-assessment on a scale of 0 to 44 related to decreasing physical function due to problems from the sternum; 0 represents the best possible health status.

The HRQoL is a validated tool that encompasses a numerical rating scale for back pain and leg pain, the Oswestry Disability Index (ODI), SF-36, Core Outcome Measures Index (COMI), and Scoliosis Research Society 22 Score (SRS-22 Score).⁶

A narrative thematic synthesis that comprised the physical, psychological, social, economic, and spiritual effects as well as the health care worker–patient relationship was undertaken for qualitative studies. Outcome measures were collected and assessed using a range of established health QoL instruments and reported in terms of QoL for quantitative studies. In addition, the type of QoL instrument employed within the studies was elucidated for comparing the scores of instruments.

Overview of all studies. Figure 1 shows the study selection process. Of the 696 publications found, a review of titles and abstracts resulted in the exclusion of 7 duplicates and 681 that did not involve patient perspectives. Following a review of the full papers of the remaining citations, 2 were excluded because of a noneligible study outcome. The remaining 6 articles met the inclusion criteria.^5,6,15-18

Characteristics of included studies. Table 1 provides the details of the 6 studies. The studies were conducted between 2002 and 2018. Of the included studies, 4 (66.7%) employed a quantitative study design,^5,6,16,18 and 2 (33.3%) employed a qualitative study design using open-ended interviews¹⁹ and unstructured interviews.¹⁷ There were 785 patients represented (754 in the quantitative and 31 in the qualitative studies), and the mean sample size was 131 ± 192.5 (range, 14 participants¹⁹ to 518 participants¹⁸).

The geographic locations of the studies included the United States,⁵ Sweden,^16,19 the United Kingdom,¹⁷ France,^6,18 Spain,⁶ Turkey,⁶ and Switzerland.⁶ All studies were conducted in hospitals; 4 studies^5,6,16,18 followed patients after discharge from the hospital. Patients were followed for different periods. In the study by Jidéus et al,¹⁶ the median follow-up time after surgery was 20 months. Dubory et al¹⁸ followed patients with SSI for at least 12 months. Whitehouse et al⁵ collected data during a 12-month follow-up period. Haddad et al⁶ followed patients preoperatively and for 6, 12, and 24 months.

Surgery types included orthopedic (3; 30%),^5,17,19 vascular (2; 20%),^16,19 general (2; 20%),^17,19 spinal (2; 20%),^6,18 and cardiac (1; 10%).¹⁷

In assessing QoL, Haddad et al⁶ obtained health-related quality of life (HRQoL) scores preoperatively and at 6, 12, and 24 months. Tanner et al¹⁷ interviewed patients in a hospital and after discharge. Andersson et al¹⁹ recruited from patients who had been examined and diagnosed with a deep SSI by a physician and had subsequently received and completed active treatment in a hospital and after discharge at home.

Results of qualitative studies. The 2 qualitative studies^17,19 were conducted between 2010 and 2012 in Sweden and the United Kingdom¹⁷; sample sizes were 14 participants in the study by Andersson et al¹⁹ and 17 participants in the study by Tanner et al.¹⁷ Sixteen (16) subthemes emerged and were integrated into 6 overarching themes including the physical, psychological, social, spiritual, and economic effects of SSI as well as and the health care worker–patient relationship (Figure 2 and Table 2).

The physical effect of SSI. Pain was the most commonly described symptom of SSI and was reported in both studies (4 participants in the study by Tanner et al¹⁷ and 5 participants in the study by Andersson et al¹⁹). In Andersson et al,¹⁹ patients with SSI described an almost unbearable feeling of pain striking suddenly. Tanner et al¹⁷ found that patients with SSI described their pain as lasting for weeks or months, leaving them feeling “utter despair” and “wanting to die.”

The smell of the wound and exudate was described in 1 study¹⁷; patients with SSI reported that the smell of the wound was terrible, and the amount of fluid was extremely embarrassing and caused them to feel shame.

Psychological effect. Patients also reported insecurity in confronting new signs and symptoms. Andersson et al¹⁹ reported that all 14 patients with SSI described a feeling of insecurity when they looked at their own wound because they had no knowledge of what a normal wound looked like. They reported in detail that physical signs and symptoms (composed of swelling, redness, and, in some cases, high temperature) could occur suddenly or a number of days after the initial surgery.

The psychological effect of SSI also included reports of depression.^17,19 Patients with SSI reported feelings of mental distress associated with feelings of depression arising from the chronic illness nature of the SSI.¹⁷ Some patients with SSI reported that depression caused isolation and that feelings of fear and worry were related to signs and symptoms of the SSI.¹⁹

The social effect of SSI on patients’ everyday life also was mentioned in both studies.^17,19 In Tanner et al,¹⁷ patients reported that SSI had repercussions for their social network and wider sets of relationships (eg, among family members and neighbors). One patient noted that he/she and their spouse struggled to cope with everyday tasks around the home because the person with the SSI usually cared for the other. Therefore, patients with SSI reported that their role within the family changed and other family members had to take on the burden of caring for them. Patients with SSI also described that being isolated, in pain, and not being able to take part in household activities put a strain on relationships; dependency and physical impairment due to SSI engendered feelings of guilt when the patient with SSI recognized the burden the situation placed on their partner or friend. The physical challenges often resulted in changes in the home, such as widening the doors and  taking away all the thresholds to allow the patient to manage everyday life.¹⁹   

The economic effect of SSI was evident in the negative impact on the finances of some patients. For some, their spouses took time off from work to become caregivers,¹⁷ and patients with limited finances suffered from the loss of income, not in the least due to the extra expenses related to dressings, medications, and visits to the hospital.¹⁹

The spiritual effect of SSI was noted in that some patients described that the presence of SSI had changed their way of looking at life and made it possible to appreciate life in a new way by not taking anything for granted and enjoying the small things.¹⁹ Patients with SSI reported that although they were not recovering from a heart attack or cancer, they were grateful to be alive after surviving what they perceived to be a serious wound infection.¹⁷

Both studies described the health care worker–patient relationship as being positive and negative. Some patients with SSI were grateful for the care provided and did not blame the hospital for the development of the SSI.^17,19 However, some patients with SSI described difficulties in understanding how or why their SSI had developed, which created a feeling of uncertainty. Some patients with SSI felt that they were not being taken seriously when they asked health care workers for help. Some patients with SSI reported a lack of dialog with the doctors and expressed a need to be recognized and treated as adults, stressing the importance of having one doctor to turn to with questions.¹⁹ Furthermore, patients with SSI were concerned about a lack of support after discharge from the hospital, and many were unsure about who to contact when symptoms of SSIs started to develop.¹⁷

Results of quantitative studies. Four (4) studies underwent quantitative synthesis^5,6,16,18; these studies employed a range of established health QoL instruments. Two (2) studies used only the SF-36,^5,18 1 used the SWI-specific questionnaire and SF-36,¹⁶ and 1 used HRQoL⁶ (Table 3). The studies were conducted between 2002 and 2018. The geographic location of the studies included the United States,⁵ Sweden,⁶ France,^6,18 and Spain, Turkey, and Switzerland.⁶ The sample size varied from 59 participants⁵ to 518 participants¹⁸ (Table 1).

Whitehouse et al⁵ determined the impact of orthopedic SSIs on quality of life. In this pairwise-matched (1:1) case–control study, matched controls were selected from the entire cohort of patients undergoing orthopedic surgery who did not have SSI. QoL was measured using SF-36. Reductions in SF-36 scores were found in physical functioning, role-physical, bodily pain, general health perceptions, vitality, social functioning, and role-emotional domains, with significant differences between matched pairs in physical functioning (P = .014) and role-physical domains (P = .022).

Jidéus et al¹⁶ evaluated QoL in 84 patients with an SWI compared with 42 patients undergoing coronary artery bypass graft over a 12-month period matched for the time of the operation, age, and sex. QoL was measured using the SF-36. The authors used the SWI-specific questionnaire; an additional 8 items for self-assessment related to sternum pain and 3 items for self-assessment related to the present local status of sternum were used. A score of 50% or more on the questionnaires was considered to indicate sternum-related problems. In this study, participants who developed an SSI deviated significantly from the normative data for the general Swedish population, apart from the body pain for all SF-36 subscales and according to the SWI-specific questionnaire: 3 of 73 patients (4.10%) had impaired physical function due to problems from the sternum, 12 of 73 patients (16.43%) had local pain from the sternum, and 9 of 73 patients (12.32%) had persistent sternum pain due to poor wound healing.

Dubory et al¹⁸ evaluated the incidence and risk factors of SSI related to surgery for spinal injury in a multicenter prospective cohort with a minimum follow-up of 12 months. The authors assessed patient clinical and functional outcomes by using SF-36 with physical and mental summaries (PCS and MCS) for 340 patients, 17 with SSI. The results demonstrated that patients with and without infection did not differ in SF-36 PCS (physical and mental summaries) (P = .8) or MCS (mental summaries) (P = .68); that is, that an SSI did not affect the QoL score.

Haddad et al⁶ evaluated the impact of SSI on surgical outcomes after adult spinal deformity surgery. Of a total of 444 surgical adult spinal deformity patients, 20 sustained an acute SSI; 60 controls with more than 2 years of follow-up were included. The authors assessed the patients at intervals (preoperatively and at 6, 12, and 24 months postoperatively) with a validated HRQoL tool.⁶ The noninfected group experienced more pronounced improvement compared with baseline values during the first year. The results up to 1 year after surgery varied among groups, mostly in the Oswestry Disability Index (ODI)(6 months), Core Outcome Measures Index (COMI)(6 and 12 months), SF-36 Physical Component Score (SF36 MCS) (6 months), and SRS 22 Mental Score (6 months) (Table 3). The COMI and ODI scores were the best parameters that could reflect the differences from baseline values between both groups at 6 and 12 months. Differences from baseline value were initially noted in the ODI (-14.69 vs -1.5; P = .029) and SRS22-Mental component score (0.20 vs -0.34; P = .049) at 6 months.

In summary, the quantitative studies similarly indicated low QoL in patients experiencing an SSI, with limitations in every field of functioning, whether physical, social, or psychological.

Methodological quality. Despite the differences in methodological design and quality, none of the 6 studies obtained more than 5 negative ratings; thus, they were all included (Table 4). All studies clearly described the aims of their research, using appropriate methodology and research design, and the research question and the recruitment strategy were clear. Furthermore, the authors collected data in a way that addressed the research issue and presented a clear statement of findings. However, in 2 studies^17,19 the relationship between researcher and participants was not reported. In 3 studies,^5,16,18 it could not be determined whether ethical issues had been considered. The rigor of the data analyses was rated as sufficient in all studies. Finally, 1 study¹⁶ was rated “unclear” because the authors did not consider the findings concerning current practice or policy, nor they did not identify new areas for research.

Two (2) qualitative and four (4) quantitative studies met the inclusion criteria for this review. Both qualitative and quantitative studies demonstrated that SSI is a debilitating condition and has a negative impact across all areas of patient functioning. The results from the qualitative studies were divided into 6 overarching themes: physical, psychological, social, spiritual, economic, and health care worker–patient relationship. The SF-36 was the most used instrument for the collection of QoL data for quantitative studies (n = 3). The quantitative studies similarly indicated low QoL, with limitations in every field of functioning, whether physical, social, or psychological.

The qualitative studies reported that SSI generated changes in the physical, emotional, social, and economic needs of patients with SSI. Patients affected by SSI have significantly more pain due to infection, which worsens physical function. Early detection and prompt intervention to treat the infection and appropriate dressing selection for SSI have been shown in the literature review by Mudge and Orsted²⁰ to help relieve pain in patients with an SSI.

Results of this review showed that patients with SSI face many challenges in interacting with others, including depression; feelings of fear and worry; impaired relationships with family members, friends, and social networks; and loss of income. Furthermore, the health care worker–patient relationship was inconsistently perceived as positive or negative. The influence of the sociocultural context of SSI was noted and had a profound influence on emotional relationships, resulting in a distancing from family, friends, and co-workers. Some patients described negative relationships with health care workers attributed to a lack of support and communication after discharge. The only positive impact of SSI was on the spiritual domain. Enjoying the small things in life and looking at their lives with gratitude helped some patients adapt to a new and sometimes difficult life situation.

Quality of life was measured using a number of instruments. The SF-36 was the most used QoL instrument.

The follow-up period of patients with SSI ranged from 12 months^5,16,18 to 24 months.⁶ The results support that SSI impacts patients’ life in the long term and that QoL is lowest during the first year after surgery.

The authors were unable to find any systematic reviews on the impact of SSI on patient QoL in the literature.

A number of important limitations need to be considered. This systematic review is limited to adult patients. Quality appraisal of the studies demonstrated a lack of reported consideration of the relationship between researcher and study participants, and ethical issues had been taken into consideration in only some of the studies included. During the initial literature search, limited qualitative studies were available to describe the patient experience for SSI. The majority of published studies are quantitative, using a variety of QoL measurement tools. Heterogeneity of reported outcomes prevented the use of meta-analysis techniques to clearly identify the impact of SSI on the lives of patients.

A systematic review of the limited related literature was conducted to determine the impact of SSI on patient QoL. The 2 qualitative studies identified showed that SSI has a significant negative impact on the QoL of patients and affects the physical, psychological, social, spiritual, and economic well-being of patients as well as the health care worker–patient relationship. Quantitative studies abstracted similarly indicated low QoL scores. Although having an SSI allowed some patients to better appreciate the small things in life and look at their lives with gratitude, this study found that, generally, SSI has a negative effect on the life of patients and their families long after they have been discharged from the hospital. Further prospective research is warranted.

Health care professionals should implement measures to help prevent and enable early diagnosis and treatment of SSIs. Consideration of the themes identified in this review might help professionals provide holistic care when treating patients who have an SSI.

Dr. Avsar is a senior postdoctoral fellow, Skin Wounds and Trauma Research Centre, and Dr. Patton is a director of nursing and midwifery research and deputy director of the Skin Wounds and Trauma Research Centre, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland. Dr. Ousey is a professor of skin integrity, director for the Institute of Skin Integrity and Infection Prevention, and Dr. Blackburn is a research fellow, University of Huddersfield Department of Nursing and Midwifery, Huddersfield, England. Mr. O’Connor is a director of academic affairs and deputy head of school, School of Nursing and Midwifery, and lead researcher, Skin Wounds and Trauma Research Centre, and Dr. Moore is a professor of nursing, head of the School of Nursing and Midwifery, and director of the Skin Wounds and Trauma Research Centre, School of Nursing and Midwifery, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland. Address all correspondence to: Pinar Avsar, PhD, Royal College of Surgeons in Ireland (RCSI), University of Medicine and Health Sciences, Dublin, Ireland; email: p.avsar.ank@gmail.com.