Surgical Site Infection in Major Lower Limb Amputation (SIMBA): an international multicentre audit: baseline unit survey

Introduction: Surgical site infection (SSI) is common after major lower limb amputation (MLLA) and is associated with significant morbidity and mortality. National and international guidelines and a best practice pathway aim to optimise care and prevent complications, but adherence is unknown. Methods: Surgical Site Infection in Major Lower Limb Amputation (SIMBA) is an international, prospective, collaborative audit which compared current practice against national and international recommendations and evaluated equipoise regarding best practice. Each participating centre completed a baseline unit survey containing Likert scale questions regarding local MLLA pathways. Responses were compared with the Vascular Society of Great Britain and Ireland’s best practice pathway, National Institute for Health and Care Excellence (NICE), Society of Vascular Surgery’s Practice management guide and the European Journal of Vascular Surgery’s Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischaemia guidelines. Results: Forty centres (30 UK, 7 Europe, 2 Australasia and 1 Asia) completed the survey, yielding a response rate of 87% (40/46). MLLA was performed by vascular surgeons in all centres, with additional specialities also undertaking MLLA surgery including orthopaedic (n=10), plastic (n=4) and general surgery (n=3). Induction antibiotic prophylaxis was given in 32 (82.1%) of the centres. Prophylactic postoperative antibiotics were ‘commonly’ or ‘always’ given in 24 (61.5%) of the centres, typically comprising a 5-day intravenous course. Incise drapes were infrequently used (used ‘never’ for iodophor (39.5%, n=15) and non-iodophor (44.7%, n=17) containing drapes). Routine follow-up was conducted in 27 centres (69.2%) and preoperative vascular imaging was ‘commonly’ or ‘always’ performed in 37 centres (92.5%). Preoperative assessment by physiotherapists and/or occupational therapists and diabetic specialists occurred ‘commonly’ or ‘always’ in 32 (82.1%) and 27 (71.1%) centres, respectively. Dietetic and psychological assessment only occurred ‘commonly’ or ‘always’ in 8 (21.6%) and 9 (25%) centres, respectively. Conclusions: This audit highlights the variability in practice, underscoring the need for consensus on best practice. Future studies should focus on generating high quality evidence to refine recommendations and reinforce adherence to guidelines to reduce SSI and improve outcomes after MLLA.