Benchmarking surgical infections: A five years NSQIP-based analysis of postoperative infectious morbidity in general surgery at a tertiary care hospital in Pakistan

Background & Objectives: Surgical site infections (SSIs) remain a leading cause of postoperative morbidity in low-and middle-income countries (LMICs). This study evaluates five years trends in postoperative infectious complications in general surgery using American College of Surgeons NSQIP data from a tertiary care hospital in Pakistan. Methodology: Retrospective analysis of 2,650 consecutive adult patients undergoing general surgical procedures from January 2020 to December 2024 at the Department of General Surgery, Aga Khan University Hospital, Karachi. Standard NSQIP variables and risk-adjusted outcomes were examined. Predictors of SSI were identified using multivariable logistic regression, and institutional performance was benchmarked via observed-to-expected (O/E) ratios. Results: The overall SSI rate was 8.0% (superficial, 4.9%; deep, 0.3%; organ/space, 2.8%), with the highest rates following hepatopancreaticobiliary (19.6%), colorectal (18.3%), and small-bowel procedures. Independent predictors of SSI were open surgical approach (OR 3.42, 95% CI 2.16–5.43), operative time >120 minutes (OR 2.76, 95% CI 1.94– 3.91), ASA class III–IV (OR 1.61, 95% CI 1.15–2.24), and diabetes mellitus (OR 1.47, 95% CI 1.03–2.11). The annual SSI rate declined significantly from 9.1% in 2020 to 6.2% in 2024 (p=0.031), and overall 30-day morbidity fell from 10.7% to 6.9% (p<0.001). Risk-adjusted morbidity improved from an O/E ratio of 1.09 in 2020 to 0.76 in 2024 (better than expected), while mortality O/E remained near 1.0 throughout. Conclusion: Despite initially elevated SSI rates compared with international NSQIP benchmarks, sustained participation in NSQIP was associated with significant reductions in infectious morbidity and achievement of better-than-expected overall outcomes. Expansion of minimally invasive surgery and reduction in operative time represent key opportunities for further improvement in LMIC settings.