Are superficial surgical site infections underrecognized in Black patients? A NSQIP database analysis

Surgical site infections (SSIs) are a leading cause of postoperative morbidity, yet whether their diagnosis varies by race remains uncertain. Because superficial SSI detection relies heavily on visible skin changes, recognition may be more challenging in patients with darker skin tones, potentially resulting in underdiagnosis. This study examined whether superficial SSI rates differ between Black and White patients undergoing abdominal surgery, and compared these findings with deep SSI, organ/space SSI, and wound disruption rates.

We conducted a retrospective cohort study of adult patients undergoing elective abdominal surgery using the 2022-2023 ACS NSQIP database. The primary analysis used 1:1 propensity score matching stratified by operative approach (open vs. minimally invasive surgery (MIS)) to compare 30-day superficial SSI incidence between Black and White patients. Matching incorporated demographic, comorbidity, and operative covariates, and post-match outcomes were compared using McNemar's test. Secondary outcomes included deep incisional SSI, organ/space SSI, and wound disruption. Multivariable logistic regression served as a sensitivity analysis to assess robustness of confounding adjustment.

Among 177,123 procedures (59,163 open; 117,960 MIS), 25,859 (14.6%) patients were Black and 151,264 (85.4%) were White. After matching, Black patients had lower superficial SSI rates compared with White patients in both open (2.54 vs. 3.60%, p < 0.001) and MIS (1.1 vs. 1.6%, p < 0.001) procedures. No significant differences were observed in deep SSI or organ/space SSI, though wound disruption was higher in Black patients after MIS (0.3 vs. 0.2%, p = 0.02). Sensitivity regression analyses confirmed these findings.

Black patients had significantly lower documented superficial SSI rates compared with White patients, despite similar or higher rates of deeper infections and wound disruption. These findings raise the possibility of under-recognition of superficial SSI in Black patients due to diagnostic challenges, with important implications for equitable surgical care.