Epidemiology and risk factors of surgical site infections in elective surgeries in Pakistan (2022-2023): a multicentre, prospective cohort study from PakSurg 1

Usama Waqar; Shaheer Ahmed; Asad Saulat Fatimi; Warda Ahmed; Russell Seth Martins; Haseeb Waheed; Illiyun Banani; Dahir Ashfaq; Asma Altaf Merchant; Ronika Devi Ukrani; Manzar Abbas; Muskan Abdul Qadir; Izza Tahir; Daniyal Ali Khan; Hareem Rauf; Mahnoor Javaid; Sarim Raheel; Muhammad Uzair; Muhammad Umar Mahar; Sehar Salim Virani; Faiqa Binte Aamir; Hamna Ganny; Mabrooka Kazi; Hajra Arshad; Muhammad Abbas Raza; Muhammad Jawad Amin Malik; Muhammad Ozair Awan; Abida Khalil Sattar; Amna Urooba; Aliya Begum Aziz; Erum Baig; Maheen Mansoor; Hina Inam; Mashal Shah; Muhammad Shahzad Shamim; Nadeem Siddiqui; Rehana Siddiqui; Sadaf Khan; Shahryar Noordin; Tabish Chawla; Syed Ather Enam; PakSurg Collaborative

doi:10.1016/j.lansea.2026.100786

Epidemiology and risk factors of surgical site infections in elective surgeries in Pakistan (2022-2023): a multicentre, prospective cohort study from PakSurg 1

Lancet Reg Health Southeast Asia. 2026 Jun 1:50:100786. doi: 10.1016/j.lansea.2026.100786. eCollection 2026 Jul.

Authors

Usama Waqar¹, Shaheer Ahmed¹, Asad Saulat Fatimi¹, Warda Ahmed¹, Russell Seth Martins¹, Haseeb Waheed¹, Illiyun Banani¹, Dahir Ashfaq¹, Asma Altaf Merchant¹, Ronika Devi Ukrani¹, Manzar Abbas¹, Muskan Abdul Qadir¹, Izza Tahir¹, Daniyal Ali Khan¹, Hareem Rauf¹, Mahnoor Javaid¹, Sarim Raheel¹, Muhammad Uzair¹, Muhammad Umar Mahar¹, Sehar Salim Virani¹, Faiqa Binte Aamir¹, Hamna Ganny¹, Mabrooka Kazi¹, Hajra Arshad¹, Muhammad Abbas Raza¹, Muhammad Jawad Amin Malik¹, Muhammad Ozair Awan¹, Abida Khalil Sattar¹, Amna Urooba¹, Aliya Begum Aziz¹, Erum Baig¹, Maheen Mansoor¹, Hina Inam¹, Mashal Shah¹, Muhammad Shahzad Shamim¹, Nadeem Siddiqui¹, Rehana Siddiqui¹, Sadaf Khan¹, Shahryar Noordin¹, Tabish Chawla¹, Syed Ather Enam¹; PakSurg Collaborative

Collaborators

PakSurg Collaborative:
Usama Waqar, Shaheer Ahmed, Asad Saulat Fatimi, Warda Ahmed, Russell Seth Martins, Haseeb Waheed, Illiyun Banani, Dahir Ashfaq, Asma Altaf Merchant, Ronika Devi Ukrani, Manzar Abbas, Muskan Abdul Qadir, Izza Tahir, Daniyal Ali Khan, Hareem Rauf, Mahnoor Javaid, Sarim Raheel, Muhammad Uzair, Muhammad Umar Mahar, Sehar Salim Virani, Faiqa Binte Aamir, Hamna Ganny, Mabrooka Kazi, Hajra Arshad, Muhammad Abbas Raza, Muhammad Jawad Amin Malik, Muhammad Ozair Awan, Abida Khalil Sattar, Amna Urooba, Aliya Begum Aziz, Erum Baig, Maheen Mansoor, Hina Inam, Mashal Shah, Muhammad Shahzad Shamim, Nadeem Siddiqui, Rehana Siddiqui, Sadaf Khan, Shahryar Noordin, Tabish Chawla, Syed Ather Enam, Laiba Kiani, Naeem Ahmed, Shafaq Hanif, Mahnoor Zahra, Amna Aslam, Haasin Iqbal, Zarish Shuja, Huzaifa Shabbir, Umm-E-Roman, Areeba Kabeer, Amerzish Shahid, Aqsa Haider, Fatima Tanveer, Marriam Nazakat, Alveena Waheed, Sana Umer Kiani, Mehrish Batool, Sana Kokab, Syed Nazar Sherazi, Mifrah Rahat Khan Sherwani, Gulnaz Khalid, Muhammad Tahir, Aisha Khatoon, Zainab Farooq, Shanza Gul, Hira Islam, Areeba Saleem, Aariz Hussain, Wajiha Shaikh, Areeba Fareed, Warisha Kanwal, Vousqa Zubair Ahmed, Aqsa Fareed, Fareeha, Sana Iqbal, Zoha Haq, Kanwar Arham, Abdul Haseeb, Anum Khalid, Iqra, Tazmeen Sabooh, Hania Arshad, Faiza Saleem, Tehreem, Fariya Majid, Sibqun Irfan, Abdul Ghafoor Qureshi, Moaaz Syed Nezami, Farhan Ahmed, Madeeha Ali, Muhammad Taha Nasim, Umer Adnan, Bilal Lodhi, Muhammad Tabish Nasim, Linta Khan, Khushi Saleem, Muneeb Khalid, Mannal Ahmed, Muhammad Ibrahim, Maryam Shaukat, Faiza Qureshi, Sneha Bheesham, Zain Javed, Taha Shaikh, Syeda Samnita Batool Zaidi, Aqsa Amjad, Huzaifa Ahmed, Fatima Abdullah, Fiza Adnan Khan, Sibgha Alam, Konain Imran, Reyan Hussain Shaikh, Muneeb Ahmed, Saba Bilal Qamar, Abdul Hadi Shahid, Sana Farhan, Hania Fatima, Arshia Jahangir, Umme Abeeha Zafar, Wamiq Ali Shaikh, Muhammad Hyedar Anwar, Muhammad Abdullah Jamil, Hashim Ishfaq, Hufriya Mondegarian, Mohammad Zakriya, Varisha Madni, Mohammad Shahmeer Chaudhry, Hamza Haider, Hunaina Abid, Komal Fida Ali, Ismail Khan, Khadija Awais Sumra, Amna Irfan Ansari, Misbah Jahangir, Aliha Shabbir, Sheza Saqib, Ahmad Jan Anab, Eisha Saadat, Aiman Sultan, Yusra Imran, Talal Bin Tariq, Kinza Jawed, Umair Saleem, Kashmala Hussain, Musa Salar, Hashim Salar, Hassan Khan Niazi, Sajjan Raja, Zayan Alidina, Mashal Waqas, Fiza Sohail Gagai, Abia Abdullah, Shiza Atif, Karishma Wali, Zainab Haider Ejaz, Maha Muzzamil Chaipiwala, Shilpa Golani, Alizeh Sonia Fatimi, Shalni Golani, Abdullah Ahmed, Khadijah Aslam, Maheen Qureshi, Muhammad Daniyal, Eman Anwar, Shahier Paracha, Salaar Ahmed, Shahzil Abdur Rehman Malik, Ayesha Nawal, Muhammad Qasim Butt, Muhammad Luqman Kaleem, Abdur Rehman, Nabiha Syed, Muhammad Waleed Ajmal, Unaiza Ahmad, Muhammad Saleem Iqbal, Nazar Hussain, Ammara Niaz, Muhammad Shoaib Bin Shakeel, Azka Irfan, Mahrukh Atif, Mahnoor Naeem, Noor Azhar, Labeeba Abdul Ghafoor, Momna Yousaf, Muhammad Bilal Ashraf, Ajia Ali Khan, Sumayya Sajid, Muhammad Ahmad Arsal, Abdul Moeid, Abdullah Nasir, Mashal Fatima Farooq, Syed Samar Ali Shah, Ahmad Hassan Gul, Irtaza Shafqat, Hafiz Muhammad Usama Zuhair, Umer Hussain, Muhammad Ali, Sarmad Naeem, Ahmad Butt, Kiran Fatima, Rameen Fatima, Maryam Haroon, Muhammad Usman Javed, Muhammad Huzaifa Khan, Muhammad Awais Ali, Sameer Ashraf, Bilal Habib, Ali Shehzad, Ammara Basit, Nahal Irshad, Abrar Ahmad, Ayyaz Ahmad, Syed Sheraz Ashiq, Mubeen Ahmad Randhawa, Adnan Ansar Sukhyra, Musharraf Ur Rehman, Ahsan Ali Akbar, Muhammad Zain Munir, Ghazi Umair Ahmad, Muhammad Zaman, Shah Ahmed Cheema, Nadeem Ahmed, Muhammad Iltaf, Ruqqia Sultana, Fazli Junaid, Wajeeha Khurshid, Muhammad Qaisar Shah, Jamal Ali, Sakhawat Ali, Salman Ahmad Khan, Muhammad Raza, Zubair Ahmed, Shakeel Akbar, Saiqa Bazai, Abdifitah Bashir Omer, Fouzia Ali, Hunniya Bint-E-Riaz, Muhammad Akmal, Muhammad Imran, Ismail Mazhar, Mir Muhammad Rai, Rao Muhammad Waleed, Maaela Khan, Amir Iqbal Ali, Maryam Zubair, Arooj Sabahat, Talha Adil, Zoha Khan, Rehnaz Riaz, Poshmal Zahid, Arwah Asif, Muhammad Qaisar Karim, Afroza Abbas, Ahmad Hassan Khan, Sufian Muhammad Zahid, Muhammad Muneer Haider, Muhammad Hassan Javeed, Areeba Mariam Mahmood, Muhammad Arsalan, Nabeel Akhtar, Saad Maqbool, Ahmed Raza, Munazzah Aziz, Muhammad Assad Javed, Bushra Kant, Muhammad Hanif, Muhammad Khurram Sajjad, Sarah Ishtiyaq, Zainab Shahid, Sidra Javaid, Areej Taswar, Fatima Batool, Syeda Minahal Kazmi, Sana Razzaq, Uroba Arshad, Amal Khan, Mahad Ali Khan, Arrham Hai, Syeda Zohva Zainub, Maham Farooq, Shehryar Javed, Muhammad Asher Javed, Anam Zafar, Eisha Faheem, Saliha Maqsood, Shaiza Jabbar, Noor Ul Zuha, Soma Siddique, Zubaria Qureshi, Muhammad Ali, Izah Sadiq, Amna Shahid, Rimsha Zahid, Khaleeq Ur Rehman, Javed Shakir, Andleeb Kanwal, Noor Fatima, Hamna Zaman, Amun Mustafa, Mohammad Ahmad Farooq, Fizza Mansoor, Irtiqua Zaheer, Maham Murtaza, Sameen Fatima Zafar, Hassan Sarwar, Muhammad Umair Amjad, Laila Khadim, Zahid Aman, Muhammad Aasim, Muhammad Waqar, Iqra Zaman, Muhammad Sheraz Ali, Mahnoor Musharaf, Hafsa Khan, Sadia Ambreen, Aqdas Faiz, Aiman Haroon, Mehreen Mushtaq Ahmad, Alishba Fatima, Maham Mehmood, Eeman Shehzad, Iman Ali, Shandana Gul, Maimoona Naeem, Shanza Abbasi, Jahangir Sarwar Khan, Rubina Shahzad, Gohar Rasheed, Ashraf, Usman Qureshi, Lubna Ijaz, Zubair, Fatima Siddiqui, Juwereya Memon, Farhana Anjum, Mohammad Shahid Khan, Adeena Noor, Fiza Lashari, Alizeh Fatima Memon, Mariam Qureshi, Amna Gopang, Aisha Shah, Marvi Mirbhar, Anousha Afzal, Abdullah Memon, Seerat Hameem, Sadia Hameed Lashary, Khushboo Devi, Adeel Rehman, Ahmed Mustafa Burney, Muhammad Alyaan Arshad, Shahid Mehmood, Muhammad Umer Farooq, Raffay Ali Gillani, Nabeel Chodhary, Saima Iqbal, Laveeza Fatima, Minahil Iqbal, Faseeh Fatima, Sara Khan, Anzil Adnan, Farooq Ahmad, Rubab Zahra, Sehar Fatima, Muhammad Fazeel Shahid, Muhammad Zulkifl, Hadia Nadeem, Muhammad Subhan Saleem, Hassan Mehmood, Muhammad Ahrar Bin Naeem, Tooba Nihal, Ayesha Yousaf Khan, Yumna Naeem, Aqsa Zainab, Laiba Ali, Saad Masood, Ali Azlan, Abdul Wasay, Abdul Wahab Mirza, Marium Mansoor, Maryam Baloch, Zain Ali Nadeem, Maha Malik, Muhammad Rafay Paracha, Muhammad Hamza Awais Khalid, Hammad Jehangir, Yashfeen Amjad, Shahab Zafar, Sameen Shafqat, Haider Ashfaq, Hamza Ashraf, Sophia Ahmed, Aaila Hameed, Areej Iftikhar, Asna Moghis, Umar Akram, Faryal Khan, Samra Shafique, Muhammad Sohaib Khan, Fasih Khalil Ur Rehman, Abdullah Arshad, Ali Nawaz Khan, Muhammad Zareen, Muhammad Idris Khan, Fauzia Afridi, Sadaf Faryal, Arif Hussain, Romana Bibi, Sara Jamil, Waseem Jamil, Sundas Mehreen, Abdul Wahab, Haseena Rehman, Saima Khattak, Faaiz Ali Shah, Ilyas Khan, Ijaz Ahmad, Kainat Ullah Khan, Ume Kulsum, Tariq Shah, Abdullah Khan, Babur Farid, Abbas Bangash, Syed Mubeen Ahmed, Ahmed Naeem, Yaser Ul Din Hoti, Farooq Afzal, Adeel Hamid, Najam Gohar, Mahin Qudeer Sheikh, Umar Abdullah, Waleed Anjum, Uzair Ahmad, Abdullah Masood, Aroob Farooqi, Suman Memon, Vashdev Khimani, Ahmed Hussain Pathan, Qurat Ul Ain, Fahad Shabir, Taskeen Waheed, Usama Ahmed Qureshi, Ramsha Anwar, Nadia Sadiq Memon, Sanjeet Kumar, Farhat Bano, Javeria Farooq, Faisal Aftab, Fehmina Raza, Muhammad Shaharyar Sabeeh, Nouman Arif, Shams Bukhari, Aamir Shahzad, Rizwan Sharif, Munazza Khalid, Muhammad Ali, Ali Waqas, Syed Fouz Hyder Abidi, Muhammad Uzair Rafique, Musfirah Younis, Wajeeha Younas, Rimsha Afzal, Laraib Mubashir, Abdul Rafay, Aqsa Bilal, Naima Khalid, Mohammad Nouman Arshad, Almas Fasih Khattak, Tarbia Hamid, Syed Sarmad Bukhari, Amjad Ali Shah, Saifullah Shafiq, Muhammad Hamza, Fatima Khan, Aamena Akhtar, Kiran Rehman, Ayesha Mobeen, Masooma Husnain, Zainab Zia, Iqra Nasir, Mohad Bin Asghar, Syed Usman Husain Shah, Zobia Majeed, Lareb Basharat, Sumaira Yasmeen, Raja Adnan, Rehan Ahmed Khan, Sohail Iqbal Sheikh, Sameen Rehan, Sobul Khan, Mohammad Ali Sohail, Naeem Karim Bhatti, Abdul Razaque Mari, Manahil Iftekhar, Sanish Abassi, Wardah Nizamani, Amna Suhail, Mahek Gul, Summiya Bhatti, Kiran Manwani, Haseeb Mehmood Qadri, Asif Bashir, Areesha Fazil Awan, Rai Muhammad Aslam, Tabassum Firdous

Affiliation

¹ Aga Khan University Hospital, Karachi, Pakistan.

Abstract

Background: Surgical site infections (SSIs) are a leading and preventable cause of postoperative morbidity in Pakistan. However, the absence of national-level data has precluded the development of targeted preventative measures. PakSurg1 aimed to quantify the burden of SSIs and evaluate associated risk factors in a multicentre cohort across Pakistan.

Methods: We conducted a prospective cohort study of 1711 patients across 28 hospitals in Pakistan from 2022 to 2023. Adult patients undergoing elective general or subspecialty surgery were followed for 30 days postoperatively. We assessed SSI incidence and identified risk factors at the patient, surgical, and hospital levels.

Findings: The overall incidence of SSIs was 9.5% (n = 163). Most SSIs were superficial (73.6%; n = 120) and managed non-surgically with antibiotics (66.9%; n = 109). On multivariable analysis, SSIs were more likely in patients undergoing trauma-related surgery (OR: 3.047 [95% CI: 1.205-7.708]), with contaminated or dirty wounds (OR: 3.245 [95% CI: 1.298-8.113]), or with longer hospital stays (OR: 1.068 [95% CI: 1.036-1.101]). Several modifiable factors were associated with lower odds of SSI. These included laparoscopic surgery (OR: 0.556 [95% CI: 0.343-0.900]), ambulatory procedures (OR: 0.598 [95% CI: 0.375-0.953]), combined chlorhexidine and povidone-iodine skin preparation (OR: 0.304 [95% CI: 0.131-0.704]), and completion of a surgical time-out (OR: 0.446 [95% CI: 0.268-0.743]). Compared to general surgery, lower SSI odds were observed in cardiac (OR: 0.223 [95% CI: 0.074-0.672]), cranio-spinal (OR: 0.292 [95% CI: 0.126-0.676]), and orthopaedic (OR: 0.216 [95% CI: 0.071-0.655]) procedures.

Interpretation: PakSurg 1 provides a national estimate of SSI incidence in elective surgeries in Pakistan and identifies key, modifiable risk factors. These findings can inform targeted, context-specific strategies to reduce SSIs and improve surgical safety nationwide.

Funding: This study received monetary funding from the Student & Trainee Initiated Research Program (MBBS Class of '88 Awards, Aga Khan University, Karachi, Pakistan).

Keywords: Disease burden; Incidence; Postoperative complications; Prevention; Risk factors; Surgical site infections; Surgical wound infection.