Original Investigation 

Global Scaling of a Surgical Infection Prevention Program to 5 Low-Resource Countries

Writing Group for the Clean Cut Investigators Group

JAMA Surg Published Online: August 13, 2025

doi: 10.1001/jamasurg.2025.2790

Key Points

Question  Can a previously validated quality improvement program shown to be effective in preventing surgical infections in Ethiopia be scaled to other low-income settings through the training of local teams by experienced implementers from Ethiopia?

Findings  This cohort study shows that the surgical infection prevention quality improvement program was implemented in 5 countries, including 1865 patients, and demonstrated that it could significantly improve compliance with infection prevention standards with an associated 49% relative risk reduction in surgical site infections.

Meaning  The surgical infection prevention program can be effectively scaled to a variety of low-resource settings with similar reduction in surgical infections.

Abstract

Importance  Surgical site infections (SSI) are a leading cause of morbidity and mortality from surgery, with higher rates in low- and middle-income countries (LMICs). Clean Cut is a multimodal, adaptive quality improvement program that aims to reduce SSI by improving compliance with perioperative infection prevention standards. The program has been successfully implemented in Ethiopia at 12 hospitals with an associated 35% reduction in SSI.

Objective  To assess whether this surgical infection prevention program implemented in Ethiopia can be effectively scaled to a variety of geographical and socioeconomic settings.

Design, Setting, and Participants  This cohort study was a quasi-experimental study of a surgical infection prevention program that was implemented in 1 hospital in each of 5 low-income countries (Liberia, Madagascar, Malawi, India, and Bolivia) from 2021 to 2024. Program introduction and scale-up relied on knowledge transfer from clinicians who had successfully implemented the same program in Ethiopia to build local expertise in each new setting. Participants were patients undergoing surgery who were followed up from their initial operation through discharge and for 30 days postoperatively using follow-up phone calls.

Exposure  Implementation of a surgical infection prevention program.

Main Outcomes and Measures  The primary outcome was 30-day SSI rate. Secondary outcomes include compliance with infection prevention standards, death, reoperation, and length of stay.

Results  Prospective data were collected for 1865 patients (mean [SD] age, 31.6 [17.5] years; 980 [52.5%] female and 885 [47.5%] male), 478 from the baseline period and 1387 from the intervention period. Thirty-day SSI rates were reduced from 28.4% to 12.1% (difference, 16.3%; 95% CI, 12.0%-20.6%; relative risk, 0.51; 95% CI, 0.38-0.67; P < .001). There were also significant improvements in use of the World Health Organization Surgical Safety Checklist, hand and skin antisepsis, antibiotic administration, instrument reprocessing, sterile field maintenance, and gauze counting.

Conclusions and Relevance  A surgical infection prevention program previously validated in Ethiopia was successful in reducing SSI in 5 LMIC hospitals in 5 other countries. This study demonstrated the scalability and efficacy of this program in preventing SSI across a range of settings. This study also demonstrates a mechanism for scaling the program expertise needed to improve compliance with standards, a step that is crucial to wider implementation.