Anemia, Copper-T Use, and Hypertension as Predictors of Surgical Site Infections in Gynecological Surgeries

Surgical Site Infections (SSIs) are one of the most common healthcare-acquired infections, having a significant impact on global morbidity in the postoperative period, length of stay, and overall healthcare utilization costs. They contribute to almost 20 30 percent of all surgical patients' hospital-acquired infections and continue to be a profound surgical outcome determinant in low and middle-income countries (LMICs), including India, where infection control practices cannot be exercised optimally due to resource constraints ⁽¹⁾. The operative fields in gynecological surgery are in close vicinity to endogenous vaginal, urinary, and gastrointestinal flora; hence, the risk of microbial contamination is high in and of itself. Reported SSI rates in the field of gynecological operations in India were found to be between 7 and 21% and thus significantly higher than the mean world rate ⁽²⁾. SSIs are multifactorial in their etiology. Risk factors that have been established are increased operating time, emergency operations, intraoperative blood loss, obesity, diabetes, and poor prophylactic antibiotic measures ^(3,4). Anemia, Copper-T (Cu-T; intrauterine contraceptive device), and hypertension (HTN) are of specific interest amongst several other comorbidities in the Indian environment, where the prevalence of these conditions is high among women belonging to reproductive and perimenopausal age groups. One of the most prevalent comorbidities among women who have undergone gynecological surgery is anemia, with a prevalence rate of more than 50 percent in India ⁽⁵⁾. Decreased hemoglobin causes poor oxygen delivery to tissues in surgical areas, damaging the neutrophil function, collagen production, and wound healing, which in turn heightens vulnerability to infections ⁽⁶⁾. The literature proves that SSI is more likely in anemic patients than in those with normal hemoglobin levels ⁽⁷⁾. The common intrauterine contraceptive device (IUD) Copper-T, as a long-term reversible method of contraception, is related to changes in local vaginal microflora and an increase in the risk of pelvic inflammatory disease and bacterial colonization ⁽⁸⁾. Gynecology surgery associated with a Cu-T presence is likely to predispose patients to ascending infections that may complicate postoperative wound healing and predispose patients to SSI. Nevertheless, it is not well-investigated as an independent predictor of SSI, especially in cohorts involving large multicenter. Another possible risk factor is hypertension (HTN), which is prevalent in women aged above 35 years. Uncontrolled hypertension negatively affects the venous circulation in the skin, and tissue healing is delayed at the wound location ⁽⁹⁾. Hypertension has been reported as a predictor of poor surgical outcomes, including SSIs, across a range of studies, although its emphasis in the gynecological context is scarce ⁽¹⁰⁾. Against this background, a multicentric observational study was carried out in the present study to assess the effectiveness of anemia, Cu-T use, and hypertension as predictors of SSIs in women undergoing surgery in the gynecology department. The identification of these associations can reinforce preoperative risk stratification and promote preoperative optimization, including anemia treatment, eliminating Cu-T before elective surgery, and controlling hypertension adequately, and can reduce the level of infections and improve postoperative outcomes.

MATERIALS AND METHODS:

This was a multicenter, ambispective observational study conducted between August 2024 and March 2025 across tertiary care hospitals in Gujarat, India.

Study Population and Eligibility

A total of 304 women aged 18 years and above who underwent major gynecological surgeries during the study period were included. Eligible patients were those who received preoperative antibiotic prophylaxis and, where applicable, postoperative antibiotics for the treatment of surgical site infections (SSIs). Women below 18 years of age, patients undergoing minor or noninvasive gynecological procedures or diagnostic interventions, immunocompromised patients (such as those receiving chemotherapy or diagnosed with HIV), and those with active infections at the time of surgery were excluded from the study.

Data Collection

Data were collected using a structured Case Record Form (CRF) that captured demographic details, surgical characteristics, comorbidities (including anemia, hypertension, history of Copper-T use, etc.), antibiotic usage patterns, and postoperative SSI outcomes.

Statistical Analysis

Data were entered into Microsoft Excel and analysed using IBM SPSS version 25. Descriptive statistics were used to summarize patient characteristics. Associations between categorical variables were tested using one-way ANOVA to assess the influence of comorbidities on SSI outcomes. A p-value <0.05 was considered statistically significant.

RESULT:

Overall Incidence of Surgical Site Infections: A total of 304 women undergoing major gynecological surgeries were included in the analysis. Surgical site infections (SSIs) were identified in 47 patients, corresponding to an overall SSI incidence of 15.46%.

1. Prevalence of Co-Morbidities Among Study Patients

The prevalence of co-morbid conditions among patients who developed surgical site infections (SSIs) is presented in

Table 1. Prevalence of Co-Morbidities Among Study Patients & SSI contribution:

Patients with multiple risk factors were counted in each relevant category. The table highlights the prevalence of co-morbid conditions among the study population. The reference p-values and their corresponding asterisks are as follows: If, p < 0.05 (*), p < 0.01 (**), and p < 0.001 (***) Hypertension, hypothyroidism, diabetes mellitus, anemia, and liver or renal disorders were the most frequently reported co-morbidities. Patients with more than one co-morbid condition were included in each relevant category. The distribution of risk factors among the study population is illustrated in Figure 1.

Figure 1: The Graph represents the distribution of Risk Factors Amongst the Study Population

2. Distribution of SSI Based on Co-Morbid Conditions

The percentage contribution of individual co-morbid conditions to total SSI cases is summarized in Table 1. Anemia accounted for the highest proportion of SSI cases, followed by hypertension and Copper-T implantation. The percentage distribution of SSI cases across co-morbid conditions is depicted in Figure 2.

Figure 2: Percentage of SSI cases per co-morbid condition

3. Distribution of SSI Based on Risk Percentage and SSI Contribution

A comparison between the risk percentage of developing SSI and the proportional contribution of each co-morbid condition to total SSI cases is shown in Table 3.

Table 3 Comparison of Risk Percentage and SSI Contribution

Copper-T implantation demonstrated the highest risk percentage, followed by anemia. The comparative distribution of risk percentage and SSI contribution by medical condition is illustrated in Figure 3.

Figure 3 Comparison of Risk Percentage and SSI contribution by Medical condition

The risk percentage for SSI was calculated as the proportion of patients with a specific co-morbid condition who developed SSI relative to the total number of patients with that condition

This was computed using the formula:

4. Medical Conditions and Their Association with Surgical Site Infections

The risk factor–wise distribution of total patients, number of SSI cases, risk percentage, and SSI contribution is detailed in Table 4.

Table 4 Risk Factor-wise Distribution of Patients and SSI Contribution