Prevalence, risk factors, and outcomes of post-surgical infections and osteomyelitis: a clinical and epidemiological analysis

Nº de DOI: 10.34896/RSI.2025.28.58.001

AUTHORS

1. Cristian Antonio Taco Santillan. General Practitioner and Master’s Degree in Health Management. Attached to Private Clinics in Ecuador. Graduate of the University of the Americas. (Sangolqui-Ecuador). https://orcid.org/0000-0001-6363-237X
2. Edwin Fabricio Pacheco Ojeda. General Practitioner. Attached to Essen Health Associates. Graduate of the Catholic University of Cuenca. (Cuenca-Ecuador). https://orcid.org/0009-0003-9691-0876
3. Domenica Cristina Aguirre Tenorio. General Practitioner. Attached to Essen Health Associates. Graduate of the Catholic University of Cuenca. (Cuenca-Ecuador). https://orcid.org/0009-0000-6730-0073
4. Dominic Martin rojas Vallejo. General Practitioner. Attached to Homero Castanier Crespo Hospital. Graduate of the Catholic University of Cuenca. (Cuenca-Ecuador). https://orcid.org/0000-0002-2714-2143
5. Daysi Yolanda Vega Cuzco. Attached to Private Clinics of Ecuador. Graduated from the University of Cuenca. (Cuenca-Ecuador). https://orcid.org/0009-0003-2457-0614

ABSTRACT

This paper aims to provide a comprehensive analysis of the current epidemiological landscape, identify key risk factors, and evaluate clinical outcomes associated with these infections, thereby contributing to improved clinical practices and patient care protocols across diverse healthcare settings.

KEY WORDS

Post-surgical infections, osteomyelitis, surgical site infections, epidemiology, risk factors, perioperative management, infection control, antibiotic resistance.

RESUMEN
Este trabajo tiene como objetivo proporcionar un análisis integral del panorama epidemiológico actual, identificar los principales factores de riesgo y evaluar los resultados clínicos asociados con estas infecciones, contribuyendo así a mejorar las prácticas clínicas y los protocolos de atención al paciente en diversos entornos de atención sanitaria.

PALABRAS CLAVE

Infecciones postquirúrgicas, osteomielitis, infecciones del sitio quirúrgico, epidemiología, factores de riesgo, manejo perioperatorio, control de infecciones, resistencia a los antibióticos.

INTRODUCTION

Post-surgical infections and osteomyelitis represent significant and persistent challenges within global healthcare systems, contributing substantially to patient morbidity, prolonged hospitalization, and increased healthcare costs. Despite advances in surgical techniques and perioperative management, the prevalence of these infections remains considerable, with rates varying markedly across regions, surgical procedures, and patient populations. Globally, post-surgical infections are reported to affect approximately 1-3% of surgeries, yet in high-risk populations or resource-limited settings, these rates can be substantially higher. Osteomyelitis, a severe bone infection often resulting from postoperative complications, further complicates patient recovery and imposes long-term health consequences. The variability in infection prevalence is influenced by multiple factors, including patient-related variables such as age, comorbidities (e.g., diabetes mellitus, immunosuppression), and nutritional status, as well as surgical-related factors like wound care, sterilization protocols, and the use of implantable devices. Environmental and hospital-related variables, including infection control practices and hospital infrastructure, also play crucial roles in modulating infection risks. Understanding the complex interplay of these epidemiological and risk factors is vital for developing targeted prevention strategies and optimizing management approaches. Clinically, post-surgical infections and osteomyelitis are associated with adverse outcomes, including increased morbidity, potential mortality, and significant resource utilization, which underscores the importance of early diagnosis and effective treatment modalities.

OBJECTIVE

Provide a comprehensive analysis of the current epidemiological landscape, identify key risk factors, and evaluate the clinical outcomes associated with these infections, thereby contributing to the improvement of clinical practices and patient care protocols in various healthcare settings.

METHODOLOGY

This study employed a descriptive and analytical approach based on a comprehensive review of recent literature, epidemiological data, and clinical reports addressing post-surgical infections and osteomyelitis. The methodology was structured in four main stages: data collection, selection criteria, analytical framework, and synthesis of findings.

A systematic search was conducted across major scientific databases including PubMed, Scopus, Web of Science, and ScienceDirect, focusing on publications between 2010 and 2024. Additional data were retrieved from the World Health Organization (WHO), Centers for Disease Control and Prevention (CDC), and global surveillance networks for healthcare-associated infections. The search strategy incorporated MeSH terms and keywords such as post-surgical infections, osteomyelitis, surgical site infections, risk factors, epidemiology, and infection control.

Articles were included if they met the following criteria: (a) peer-reviewed publications in English or Spanish, (b) studies reporting epidemiological data, clinical outcomes, or management strategies related to post-surgical infections or osteomyelitis, and (c) inclusion of quantitative or qualitative analyses relevant to healthcare settings. Studies were excluded if they lacked sufficient methodological detail, addressed non-surgical infections, or presented outdated or duplicated data.

Data were categorized and analyzed under three core domains:

• Epidemiology and prevalence of post-surgical infections and osteomyelitis across global and regional contexts.
• Risk factors associated with patient demographics, surgical procedures, and hospital environments.
• Clinical outcomes and management strategies, including diagnostic methods, therapeutic interventions, and health system impacts.

Each domain was synthesized to identify trends, knowledge gaps, and interconnections influencing infection rates and patient outcomes. Quantitative data were compared descriptively across studies, while qualitative insights were integrated to support interpretative analysis.

Findings were summarized to generate a comprehensive overview of the current global burden, risk determinants, and clinical management of these infections. Cross-validation was achieved through triangulation of data from multiple sources, ensuring reliability and representativeness of the results. Ethical considerations were upheld through the exclusive use of secondary data from published and publicly accessible sources.

RESULTS

Epidemiology and Prevalence of Post-Surgical Infections and Osteomyelitis:

What are the current global and regional rates of post-surgical infections and osteomyelitis?

Globally, the rates of post-surgical infections and osteomyelitis demonstrate considerable variability depending on geographical and socioeconomic factors, pointing to complex interconnections between healthcare infrastructure, patient demographics, and disease management practices. For instance, the incidence of surgical site infections (SSI) is particularly high in some low-resource settings, with the Amhara region of Ethiopia documenting a strikingly high cumulative SSI rate of 39.1% among general surgery patients, which surpasses rates reported in other parts of the country as well as in several other African and Asian nations [1]. Such regional discrepancies may be attributable to differences in the implementation and rigor of infection prevention and control measures during the perioperative period, highlighting the importance of standardized protocols to reduce infection burden [1]. Meanwhile, osteomyelitis rates also reflect stark global inequities, the reported incidence of pediatric osteomyelitis in low-income countries ranges dramatically from 43 to 200 per 100,000 people, a figure significantly higher than the 1.94–13 per 100,000 seen in high-income countries [2]. These disparities are further compounded in regions such as Sub-Saharan Africa, where the higher incidence of osteomyelitis is closely linked to factors like poverty, malnutrition, and limited access to timely diagnosis and effective management, driving up both acute and chronic disease burdens [2]. Notably, anatomical and demographic characteristics influence osteomyelitis patterns, with the tibia being the most commonly affected bone and incidence peaking among males in the second decade of life, further underlining the need for context-specific interventions [2]. Addressing these interrelated challenges will require multifaceted strategies, including strengthening infection control practices, improving early diagnostic capabilities, and targeting high-risk populations to reduce both post-surgical infection and osteomyelitis rates worldwide.

How do prevalence rates vary by surgical type and patient demographics?

Prevalence rates of surgical site infections (SSIs) and related complications show marked variability when analyzed by surgical type and patient demographics, highlighting the necessity to consider both procedural and population-specific factors in surveillance and prevention strategies. The incidence density of in-hospital SSIs is highly dependent on the nature of the surgical procedure, with rates ranging from 0.2 to 5.7 per 1000 post-operative patient-days, and the highest incidence densities observed in colorectal (COLO) operations compared to notably lower rates in knee prosthesis (KPRO) and laminectomy (LAM) operations [3]. These differences are further influenced by patient demographics, for example, the median patient age varies significantly by procedure, from 31 years in cesarean section (CSEC) to 72 years in hip prosthesis (HPRO) surgeries, indicating that age distribution within surgical cohorts may contribute to differing risk profiles and outcomes [3]. Additional demographic factors, such as the proportion of urgent procedures and sex distribution, also vary widely—for instance, urgent operations account for 54% of CSEC but only 2.1% of KPRO cases, while the male-to-female ratio is highest in coronary artery bypass graft (CABG) and lowest in CHOL, HPRO, and KPRO procedures [3]. These interconnections between surgical type and demographic variables underscore the complexity of accurately assessing and comparing prevalence rates, necessitating careful stratification by procedure and population group. Ultimately, tailored intervention strategies that account for the unique risk profiles of specific surgical populations are essential to effectively reduce adverse outcomes and ensure equitable quality of care across diverse demographic groups.

What methods are used to accurately assess and report infection rates in clinical settings?

Accurate assessment and reporting of infection rates in clinical settings rely on a combination of methodological rigor and targeted surveillance activities, ensuring data reflect true infection burdens and guide quality improvement initiatives. Central to this process are estimation techniques that consider both the numerator (number of infections) and the appropriate denominator, such as patient-days or device-days, to yield meaningful rates, for example, specific estimation methods have been developed to identify suitable denominators for central venous catheter-associated bloodstream infections, addressing the complexity of comparing rates across diverse clinical contexts [4]. To further refine these comparisons and improve the validity of internal and external benchmarking, stratification and risk stratification methodologies are employed to account for heterogeneity in patient populations, such as differences in age, sex, and severity of illness [4]. In addition, surveillance activities form the backbone of infection rate assessment, requiring the systematic collection and analysis of objective, quantifiable data compiled for facility-wide quality assurance and performance improvement (QAPI) programs [5]. The integration of these methods enables healthcare providers to identify trends, compare performance across units or institutions, and implement targeted interventions to reduce infection risk. Ultimately, sustained accuracy in infection rate reporting depends on continuous monitoring, use of validated methodologies, and ongoing quality improvement efforts to adapt to evolving clinical challenges.

Risk Factors Associated with Post-Surgical Infections and Osteomyelitis:

Which patient-related factors contribute most significantly to infection risk after surgery?

Among the various patient-related factors contributing to infection risk after surgery, a multifactorial approach is necessary to comprehensively understand their influence, as no single characteristic exclusively determines susceptibility to surgical site infections (SSIs) [6]. Smoking emerges as a particularly significant modifiable risk factor, as it impairs tissue healing and immune responses, thereby increasing the likelihood of postoperative infections [6]. While age has been considered a potential risk factor—with patients over 75 years generally experiencing higher infection rates—the evidence remains mixed, as some studies report that age alone does not reach statistical significance as a standalone predictor, but rather may interact with other comorbidities to elevate risk [7]. Furthermore, elderly patients often present with chronic underlying diseases that compromise physiological defenses and immune function, further compounding their vulnerability to infection [7]. These interconnections highlight the importance of a comprehensive assessment of patient history, lifestyle behaviors, and underlying chronic conditions when evaluating surgical candidates, as adjusting for these interconnected variables is crucial to accurately estimating and mitigating infection risk [6]. Therefore, interventions should focus not only on preoperative optimization—such as smoking cessation and the management of chronic illnesses—but also on individualized risk stratification to enhance surgical outcomes and reduce infection rates.

How do surgical techniques and perioperative practices influence the likelihood of infection and osteomyelitis?

Surgical techniques and perioperative practices are intimately linked to the likelihood of infection and osteomyelitis, with their impact extending across diagnostic precision, intervention timing, and infection control measures. Preoperative imaging modalities, such as MRI, provide valuable insights into the extent of infection but must be complemented by intraoperative assessments to ensure thorough removal of necrotic bone and tissue, as incomplete debridement remains a significant risk factor for persistent infection [8]. This interconnection highlights the necessity for real-time surgical decisions to adapt to findings beyond what imaging alone can reveal. Furthermore, aggressive surgical interventions, particularly in the context of high-energy trauma or open fractures, can paradoxically increase the risk of postoperative osteomyelitis and severe soft-tissue infections, underscoring the need for judicious surgical planning and technique selection [9]. The pathology report following surgery plays a critical role in this continuum, guiding the need for additional debridement to further reduce infection risk, thus integrating intraoperative judgment with postoperative pathological feedback for comprehensive infection management [8]. Given these complexities, the coordination of multidisciplinary perioperative practices—including timely surgical debridement, vigilant intra- and postoperative monitoring, and integration of both imaging and pathology findings—is essential to minimize infection rates and prevent the progression to chronic osteomyelitis. Emphasizing tailored surgical approaches and rigorous perioperative protocols remains imperative to optimize patient outcomes and calls for ongoing refinement of best practices through research and clinical vigilance.

What role do hospital and environmental variables play in the development of these complications?

Hospital and environmental variables play a critical role in the development of complications such as inpatient falls, which can significantly impact patient outcomes, particularly in surgical populations. Despite the recognition that the physical hospital environment is a common contributing factor to falls with injuries among patients, current research reveals substantial gaps in understanding exactly how inpatient unit design influences fall rates [10]. This lack of clarity is concerning, given that the environment is implicated in nearly 40% of severe or fatal hospital falls, signaling a direct link between physical surroundings and patient safety outcomes [10]. Furthermore, the limited scope and generalizability of existing studies—often confined to single, non-VHA hospitals or a small number of units—hinders the ability to draw robust, system-wide conclusions that could inform effective interventions [10]. The interplay between environmental factors, such as unit layout, accessibility, and visibility, and hospital-specific practices underscores the necessity for comprehensive research that identifies specific design features contributing to complications like falls. Addressing these knowledge gaps is essential for developing targeted strategies that reduce preventable adverse events and improve patient safety across diverse healthcare settings.

Clinical Outcomes and Management Strategies for Post-Surgical Infections and Osteomyelitis:

What are the short-term and long-term clinical outcomes for patients with post-surgical infections and osteomyelitis?

The clinical trajectory of patients with post-surgical infections and osteomyelitis is frequently marked by unfavorable short-term and long-term outcomes, largely due to the interplay of antibiotic resistance, the refractory nature of the disease, and the complexity of treatment modalities [11]. Methicillin-resistant S. aureus (MRSA) infections in particular are associated with heightened illness severity and present significant therapeutic challenges, given their resistance to β-lactam antibiotics, which often necessitates prolonged antimicrobial therapy and multiple surgical interventions [11]. This resistance not only complicates initial management but also increases the likelihood of persistent infection, as seen with extremity osteomyelitis, where standard treatments commonly fail to achieve eradication, perpetuating a cycle of recurrent infections and additional surgical debridements [11]. Furthermore, the need for aggressive approaches—such as radical debridement in the acute phase—directly impacts both the immediate clinical stabilization and the prevention of future re-colonization, thereby influencing long-term outcomes [11]. The interconnected domains of surgical management and antibiotic stewardship are thus critical, as delays in effective antimicrobial therapy following debridement can enable residual bacteria to persist and undermine treatment success over time [11]. Given these challenges, early recognition of refractory cases and tailored, aggressive intervention strategies are essential to mitigate complications, reduce recurrence rates, and ultimately improve both limb-specific function and overall patient prognosis in this difficult-to-treat population [11].

Which diagnostic and therapeutic interventions are most effective for managing these infections?

An integrated approach to the management of infectious diseases relies heavily on timely and accurate diagnostics, which directly influences the choice and effectiveness of therapeutic interventions. Early diagnosis is paramount, facilitating the prompt initiation of appropriate antimicrobial therapy that can significantly reduce both the severity and duration of symptoms in symptomatic patients [12]. Laboratory tests, such as blood, urine, and respiratory cultures, play a crucial role in identifying the causative organisms and guiding antimicrobial selection, particularly in complex cases like osteomyelitis, where delayed or inaccurate diagnosis may lead to chronic infection or complications [13]. Furthermore, advanced molecular diagnostics have improved the detection of pathogens and antimicrobial resistance, yet their clinical utility is maximized only when integrated with robust antimicrobial stewardship programs to ensure test results translate into optimized patient management [13]. Ultimately, refining diagnostic stewardship and ensuring prompt, targeted therapy are necessary interventions to improve outcomes, minimize resistance, and contain healthcare costs in the management of infectious diseases.

How does infection impact overall patient morbidity, mortality, and healthcare resource utilization?

Infection exerts a profound influence on overall patient morbidity, mortality, and healthcare resource utilization, with healthcare-associated infections (HAIs) and sepsis representing critical drivers of adverse outcomes across diverse patient populations. Notably, more than 24% of patients affected by healthcare-associated sepsis succumb each year, underscoring a substantial impact on survival rates and reflecting the severity of these infections within the hospital environment [14]. This risk is even more pronounced among patients in intensive care units (ICUs), where infections contribute to a mortality rate of 52.3%, and among those with antimicrobial-resistant infections, who face a two- to threefold increase in the likelihood of death [14]. The interconnectedness of infection and healthcare resource utilization is evident in the increased need for extended hospital stays, additional interventions, and complex treatments, all of which escalate hospital expenditures and strain healthcare systems [14][15]. Furthermore, infections such as sepsis disproportionately impact vulnerable populations, including the elderly and those with underlying frailty, amplifying both morbidity and resource demands due to their heightened susceptibility and the frequent presence of comorbidities [16]. These interrelated effects highlight the urgent necessity for robust preventative strategies and targeted interventions aimed at reducing infection incidence, improving patient outcomes, and alleviating the substantial burden placed on healthcare resources.

DISCUSSION

The findings of this comprehensive analysis underscore the significant global burden of post-surgical infections and osteomyelitis, highlighting substantial disparities influenced by socioeconomic status, healthcare infrastructure, and regional practices. The notably higher prevalence rates in low-resource settings, such as Ethiopia’s Amhara region, emphasize the critical need for strengthening infection prevention protocols, including adherence to sterile techniques, perioperative management, and postoperative care. The pronounced variation in osteomyelitis incidence between low- and high-income countries further illustrates the impact of factors like poverty, malnutrition, and limited access to timely surgical intervention, suggesting that targeted public health strategies are necessary to address these underlying determinants. Anatomical and demographic factors, such as the predilection of the tibia in osteomyelitis cases and increased susceptibility among certain age groups or sexes, warrant tailored prevention and treatment approaches. The observed correlation between surgical type and infection risk advocates for procedure-specific protocols, emphasizing meticulous surgical techniques, intraoperative debridement, and postoperative monitoring to reduce complication rates. Moreover, the identification of individual patient risk factors—such as smoking, comorbidities, and age—calls for personalized preoperative assessments and optimization to mitigate infection susceptibility. Despite advances in diagnostic technologies, challenges remain in ensuring accurate, timely detection of infections, integrating molecular diagnostics and continuous surveillance can enhance diagnostic precision and guide more effective antimicrobial therapy. However, the study’s reliance on variable methodologies across regions highlights a limitation, as inconsistent data collection and reporting may influence prevalence estimates and hinder comparability. Additionally, environmental and hospital factors, including unit design and safety protocols, are crucial yet often underappreciated components influencing infection rates. The clinical consequences—ranging from prolonged hospitalizations to increased morbidity and mortality—accentuate the importance of multidisciplinary management, aggressive surgical debridement, and judicious antimicrobial stewardship. Future research should focus on developing standardized infection control protocols adaptable to diverse healthcare settings, exploring innovative diagnostic tools, and evaluating the efficacy of region-specific intervention strategies. Addressing systemic barriers and regional disparities remains essential for reducing the global impact of these infections. Overall, this analysis advocates for a multifaceted approach—combining epidemiological insights, clinical best practices, and health system strengthening—to effectively combat post-surgical infections and osteomyelitis, ultimately improving patient outcomes worldwide.

CONCLUSIONS

Post-surgical infections and osteomyelitis remain pressing challenges that continue to undermine patient safety and strain healthcare systems worldwide. Despite notable progress in surgical innovation and infection control, significant disparities persist between high- and low-income regions, largely driven by inequities in healthcare access, infrastructure, and adherence to standardized preventive protocols. This analysis demonstrates that infection risk is multifactorial—shaped by patient-related factors such as comorbidities and smoking habits, procedural determinants including the type and complexity of surgery, and institutional variables encompassing sterilization practices and hospital environment. Early diagnosis and prompt, targeted treatment are critical to improving outcomes and reducing complications, particularly in the context of antibiotic resistance and recurrent infections. Integrating rigorous surveillance systems, molecular diagnostics, and multidisciplinary care pathways will be essential for enhancing detection accuracy and therapeutic efficacy. Ultimately, addressing the global burden of post-surgical infections and osteomyelitis requires a coordinated effort—uniting clinical excellence, public health policy, and equitable resource allocation—to minimize preventable complications and improve the quality of surgical care across diverse healthcare settings.

FUTURE DIRECTIONS

Future research should focus on standardizing global surveillance frameworks to improve data comparability and facilitate cross-regional benchmarking of infection rates. The development of predictive risk models incorporating artificial intelligence and machine learning may enhance individualized patient assessment and perioperative decision-making. Expanding access to advanced diagnostic technologies, particularly in low-resource settings, remains imperative for early detection and effective management of infection. Furthermore, studies evaluating the cost-effectiveness and clinical impact of antimicrobial stewardship programs could provide valuable insights for optimizing antibiotic use and reducing resistance trends. Multicenter clinical trials are also needed to assess novel surgical materials, biofilm-resistant implants, and adjunctive therapies that may lower infection rates and improve long-term outcomes. Finally, policy-driven initiatives aimed at strengthening hospital infrastructure, promoting continuous medical education, and integrating infection control training into surgical curricula will be crucial to sustaining global progress in infection prevention and patient safety.

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