Health Care-Associated Infections following Major Neonatal Surgery in a Resource-Limited Setting: Risk Factors and Outcomes from Southern Tunisia

Health care-associated infections (HAIs) remain among the most serious complications in neonatal surgery, particularly in resource-limited settings where infection control is often suboptimal. This study aimed to identify risk factors for HAIs following major thoracic and abdominal neonatal surgery in southern Tunisia.We conducted a retrospective cohort study of neonates who underwent major non-cardiac abdominal or thoracic surgery at Hedi Chaker University Hospital, Sfax, Tunisia, between April 2015 and March 2025.A total of 361 neonates underwent major abdominal or thoracic surgery during the 10-year study period. The male-to-female ratio was 1.3:1. The most common surgical conditions were esophageal atresia (<i>n</i> = 105), duodenal atresia (<i>n</i> = 42), and anorectal malformations (<i>n</i> = 39). Overall, 99 neonates (27.4%) developed one or more HAIs during their postoperative course. On multivariable logistic regression, four variables were independently associated with HAIs. These variables included cardiac comorbidities (odds ratio [OR] = 2.205; <i>p</i> = 0.007), gestational age <37 weeks (OR = 2.448; <i>p</i> = 0.009), postoperative intubation time >30 hours (OR = 2.338; <i>p</i> = 0.002), and surgery duration >120 minutes (OR = 2.471; <i>p</i> = 0.006).HAIs in neonatal surgery remain a major challenge in resource-constrained settings. In addition to patient- and surgery-related factors, structural limitations in perioperative care and infection control play a crucial role. Strengthening neonatal intensive care unit (NICU) capacity, ensuring consistent access to antibiotics and antiseptics, and optimizing perioperative protocols are essential to reduce infection rates and improve outcomes. · Cardiac anomalies emerged as a significant independent predictive factor of HAIs in our cohort.. · Prematurity is an independent risk factor for HAIs following neonatal surgery.. · Prolonged surgical duration was independently associated with an increased risk of HAIs.. · Prolonged postoperative intubation emerged as a strong independent predictive factor of HAIs..