WHO Surgical Site Infection Prevention Guidelines Web ... · antiseptic agent on at least the night...

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WHO Surgical Site Infection Prevention Guidelines

Web Appendix 1

Overview of available relevant guidelines

on surgical site infection prevention

Three comprehensive national guidelines have been published over the past 5 years on

the prevention of SSI (1-3). The guidelines issued in 1999 by the CDC (4) have been

updated recently, but they have not yet been published (5). In addition, 2 guidelines

(6, 7) and one systematic review (8) have been published on surgical antibiotic

prophylaxis. All published guidelines are from high-income countries.

The United States Institute of Health Improvement (9, 10), the United Kingdom

Department of Health (11) and Health Protection Scotland (12) have also introduced

“care bundles” for the prevention of SSI. A care bundle is a set of key evidence-based

interventions that improve patient care and outcome when used together. However,

unlike guidelines, the SSI care bundles have not undergone a systematic review. A

summary of recommendations from various SSI guidelines and care bundles are

presented in web Appendices 2-27, respectively.

For the purpose of this review, we have analysed guidelines published since 2011 by

the UK-based National Institute for Health and Care Excellence (NICE) (2), the

Society for Healthcare Epidemiology of America (SHEA)/Infectious Diseases

Society of America (IDSA) (1), The Royal College of Physicians of Ireland (3) and

the unpublished CDC draft version of the update (5).

In 2012, the European Union project entitled Prevention of hospital infections by

intervention and training (PROHIBIT) analysed all available guidelines for the

prevention of SSI and found a considerable variation among European countries (13).

In summary, 12 of 21 countries had a single document defining their individual

recommendations for specific measures related to the prevention of SSI. Of the

remaining 9 countries, between 2 and 4 separate documents were used to cover most

preventive measures. Three countries had a separate document on air quality in the

OR and 5 countries had a separate document for preoperative antibiotic prophylaxis.

The systematic review performed for the WHO report on the burden of endemic HAI

worldwide clearly indicated that SSI is a major source of morbidity and mortality

(14) . Furthermore, the summary of SSI guidelines presented here (see Table 1.1)

showed that some key factors with an impact on SSI are not addressed and clearly

identified a need for the development of global guidelines. As a result, systematic

reviews of 27 topics related to SSI prevention have been conducted to allow the

WHO GDG to make clear recommendations based on an in-depth analysis of the

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sources and strength of the available evidence.

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Table 1.1. Summary of guidelines by topic

TOPICS WHO

2016

SHEA/IDSA

2014

NICE*

2008/2013

RCSI

2012

PREOPERATIVE

Preoperative

bathing/showering

Yes

Conditional recommendation,

moderate to very low quality

of evidence

It is good clinical practice for

patients to bathe or shower

prior to surgery. Either plain

soap or an antiseptic soap may

be used for this purpose. Due to

very low quality evidence, the

panel decided not to formulate

a recommendation the use of

chlorhexidine gluconate (CHG)

cloths for the purpose of

reducing surgical site infection

(SSI).We suggest not using

CHG cloths for the purpose of

reducing SSI.

Unresolved issue

Reduces microbial load,

but no definite proof

that it reduces SSI.

Yes

The benefits of preoperative

bathing or showering with

antiseptics for the prevention of

SSI appear to be uncertain.

Evidence for the most effective

type of antiseptic wash also

appears to be inconclusive and

further research is needed.

Yes (1B)

Wash the patient/ensure that

the patient has showered (or

bathed/washed if unable to

shower) on day of or day

before surgery.

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TOPICS WHO

2016

SHEA/IDSA

2014

NICE*

2008/2013

RCSI

2012

PREOPERATIVE

Hair removal

Avoid

Strong recommendation,

moderate quality of evidence

In patients undergoing any

surgical procedure, hair should

either not be removed or, if

absolutely necessary, should be

removed only with a clipper.

Shaving is strongly discouraged

at all times, whether

preoperatively or in the

operating room.

Avoid: II

Do not remove unless

hair will interfere with

the operation.

If hair removal is

necessary, remove

outside the operating

room by clipping.

Avoid

Evidence for preoperative hair

removal in reducing SSI rates is

insufficient. If hair removal is

necessary, then clipping may be

associated with a reduced rate

of infection.

Avoid: 1A

Avoid hair removal at the

surgical site. If hair must be

removed, use single-patient

use clippers and not razors.

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TOPICS WHO

2016

SHEA/IDSA

2014

NICE*

2008/2013

RCSI

2012

PREOPERATIVE

Screening and decolonization

for Staphylococcus aureus


moderate quality of evidence.

The panel recommends that

patients undergoing

cardiothoracic and orthopaedic

surgery with known nasal

carriage of S. aureus should

receive perioperative intranasal

applications of mupirocin 2%

ointment with or without a

combination of CHG body

wash.



.

II

Screen for S. aureus and

decolonize surgical

patients with an anti-

staphylococcal agent in

the preoperative setting

for high-risk

procedures, including

some orthopaedic and

cardiothoracic

procedures

-

-

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TOPICS WHO

2016

SHEA/IDSA

2014

NICE*

2008/2013

RCSI

2012

PREOPERATIVE

The panel suggests considering

to treat also patients with

known nasal carriage of S.

aureus undergoing other types

of surgery with perioperative

intranasal applications of

mupirocin 2% ointment with or

without a combination of CHG

body wash.

Surgical antibiotic

prophylaxis

Yes


low quality of evidence

When indicated (depending on

the type of operation), surgical

antibiotic prophylaxis should be

administered prior to the

surgical incision.

I

Administer only when

indicated.

I

Administer within 1

hour of incision to

maximize tissue

concentration.

Yes

Antibiotic prophylaxis should

not be used routinely for clean

non-prosthetic uncomplicated

surgery.

When antibiotic prophylaxis is

needed, a single dose of

antibiotic intravenously on

starting anaesthesia should be

considered. However,

prophylaxis should be given

earlier for operations in which a

tourniquet is used.

Yes: 1A

Single dose only unless

otherwise indicated. Give an

additional dose of antibiotic if

the surgical procedure is

prolonged or there is major

intraoperative blood loss

(>1.5 L in adults or 25mL/kg

in children). Ensure that the

antibiotic is given at induction

(within 60 minutes before

skin incision).

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TOPICS WHO

2016

SHEA/IDSA

2014

NICE*

2008/2013

RCSI

2012

PREOPERATIVE

Yes



Surgical antibiotic prophylaxis

should be administered within

120 minutes before incision,

while considering the half-life

of the antibiotic.

II

Stop agent within 24

hours after the

procedure for all

procedures.

Evidence suggests that

administering antibiotics after

rather than before, tourniquet

inflation may be associated with

a reduced rate of SSI, but


In surgery where a tourniquet

is to be applied, a 15-minute

period is required between the

end of antibiotic

administration, and tourniquet

application.

Smoking cessation

-

I

Encourage smoking

cessation within 30 days

of procedure.

-

-

TOPICS WHO SHEA/IDSA NICE* RCSI

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2016

2014

2008/2013

2012

PREOPERATIVE

Preoperative infections

-

I

Identify and treat

infections (for example,

urinary tract infection)

remote to the surgical

site prior to elective

surgery. Do not

routinely treat

colonization or

contamination.

-

-

Extended-spectrum beta-

lactamase colonization

No recommendation.

Due to the lack of evidence, the

panel decided not to formulate a

recommendation.

TOPICS WHO SHEA/IDSA NICE* RCSI

of 44

2016

2014

2008/2013

2012

Corticosteroid or

immunosuppressive

medication


very low quality of evidence

The panel suggests not to

discontinue

immunosuppressive medication

prior to surgery for the purpose

of preventing SSI.

III

Avoid

immunosuppressive

medication in the

perioperative period if

possible

- -

TOPICS WHO

2016

SHEA/IDSA

2014

NICE*

2008/2013

RCSI

2012

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Nutrition




the administration of oral or

enteral multiple-nutrient

enhanced nutritional formulas

for the purpose of preventing

SSI in underweight patients

who undergo major surgical

operations.

I

Do not routinely delay

surgery to provide

parenteral nutrition.

Hypoalbuminemia: no

recommendation.

Although a noted risk

factor, do not delay

surgery for the use of

total parenteral

nutrition.

- -

TOPICS WHO

2016

SHEA/IDSA

2014

NICE*

2008/2013

RCSI

2012

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Mechanical bowel

preparation

Conditional

recommendation,

moderate quality of

evidence

Preoperative oral

antibiotics combined

with mechanical

bowel preparation

should be used to

reduce the risk of SSI

in adult patients

undergoing elective

colorectal surgery.


moderate quality of

evidence

Mechanical bowel preparation

alone (without administration of

oral antibiotics) should not be

used for the purpose of reducing

SSI in adult patients undergoing

elective colorectal surgery.

- - -

TOPICS WHO

2016

SHEA/IDSA

2014

NICE*

2008/2013

RCSI

2012

Blood transfusion

II

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-

Blood transfusions

increase the risk of SSI

by decreasing

macrophage function.

Reduce blood loss and

the need for blood

transfusion to the

greatest extent possible.

-

-

TOPICS WHO

2016

SHEA/IDSA

2014

CDC

(unpublished draft)

2014

NICE*

2008/2013

RCSI

2012

PREOPERATIVE

Preoperative

bathing/showering

Yes


moderate to very low quality

of evidence

It is good clinical practice for

patients to bathe or shower

prior to surgery. Either plain

soap or an antiseptic soap may

be used for this purpose. Due to

very low quality evidence, the

panel decided not to formulate

a recommendation the use of


cloths for the purpose of

reducing surgical site infection

(SSI).We suggest not using

CHG cloths for the purpose of

Unresolved issue

Reduces microbial load,

but no definite proof

that it reduces SSI.

Yes (1B)

Advise patients to shower

or bathe (full body) with

either soap (antimicrobial or

non-antimicrobial) or an

antiseptic agent on at least

the night before the

operative day.

No recommendation

No recommendation can be

made regarding the optimal

timing of the preoperative

shower or bath, the total

number of soap or antiseptic

Yes

The benefits of preoperative

bathing or showering with

antiseptics for the prevention of

SSI appear to be uncertain.

Evidence for the most effective

type of antiseptic wash also

appears to be inconclusive and


Yes (1B)

Wash the patient/ensure that

the patient has showered (or

bathed/washed if unable to

shower) on day of or day

before surgery.

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reducing SSI. agent applications required,

or the use of CHG

washcloths for the

prevention of SSI.

TOPICS WHO

2016

SHEA/IDSA

2014

CDC

(unpublished draft)

2014

NICE*

2008/2013

RCSI

2012

PREOPERATIVE

Hair removal

Avoid



In patients undergoing any

surgical procedure, hair should

either not be removed or, if

absolutely necessary, should be

removed only with a clipper.

Shaving is strongly discouraged

at all times, whether

preoperatively or in the

operating room.

Avoid: II

Do not remove unless

hair will interfere with

the operation.

If hair removal is

necessary,

remove outside the

operating room by

clipping.

-

Avoid

Evidence for preoperative hair

removal in reducing SSI rates is

insufficient. If hair removal is

necessary, then clipping may be

associated with a reduced rate

of infection.

Avoid: 1A

Avoid hair removal at the

surgical site. If hair must be

removed, use single-patient

use clippers and not razors.

of 44

TOPICS WHO

2016

SHEA/IDSA

2014

CDC

(unpublished draft)

2014

NICE*

2008/2013

RCSI

2012

PREOPERATIVE

Screening and decolonization

for Staphylococcus aureus



The panel recommends that

patients undergoing

cardiothoracic and orthopaedic

surgery with known nasal

carriage of S. aureus should

receive perioperative intranasal

applications of mupirocin 2%

ointment with or without a

combination of chlorhexidine

gluconate (CHG) body wash.

.


II

Screen for S. aureus and

decolonize surgical

patients

with an anti-

staphylococcal agent in

the preoperative setting

for high-risk

procedures, including

some orthopaedic

and cardiothoracic

procedures

-

-

-

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.

TOPICS WHO

2016

SHEA/IDSA

2014

CDC

(unpublished draft)

2014

NICE*

2008/2013

RCSI

2012

PREOPERATIVE


to treat also patients with

known nasal carriage of S.

aureus undergoing other types

of surgery with perioperative

intranasal applications of

mupirocin 2% ointment with or

without a combination of


body wash.

of 44

Surgical antibiotic

prophylaxis

Yes



When indicated (depending on

the type of operation), surgical

antibiotic prophylaxis should be

administered prior to the

surgical incision..

I

Administer only when

indicated.

I

Administer within 1

hour of incision to

maximize tissue

concentration.

Yes: 1B

Administer a preoperative

antimicrobial agent only

when indicated, i.e. based

on published clinical

practice guidelines and

timed so that a bactericidal

concentration of the agent is

established in the serum and

tissues when the incision is

made.

Yes

Antibiotic prophylaxis should

not be used routinely for clean

non-prosthetic uncomplicated

surgery.

When antibiotic prophylaxis is

needed, a single dose of

antibiotic intravenously on

starting anaesthesia should be

considered. However,

prophylaxis should be given

earlier for operations in which a

tourniquet is used.,

Yes: 1A

Single dose only unless

otherwise indicated. Give an

additional dose of antibiotic if

the surgical procedure is

prolonged or there is major

intraoperative blood loss

(>1.5 L in adults or 25mL/kg

in children). Ensure that the

antibiotic is given at induction

(within 60 minutes before

skin incision).

TOPICS WHO

2016

SHEA/IDSA

2014

CDC

(unpublished draft)

2014

NICE*

2008/2013

RCSI

2012

PREOPERATIVE

Yes



Surgical antibiotic prophylaxis

should be administered within

120 minutes before incision,

while considering the half-life

of the antibiotic.

II

Stop agent within 24

hours after the

procedure for all

procedures.

No recommendation No further refinement of

timing can be made for

preoperative antimicrobial

agents based on clinical

outcomes.

Yes: 1A

Administer the appropriate

parenteral prophylactic

antimicrobial agent prior to

skin incision for all

caesarean sections.

Evidence suggests that

administering antibiotics after

rather than before, tourniquet

inflation may be associated with

a reduced rate of SSI, but


In surgery where a tourniquet

is to be applied, a 15-minute

period is required between the

end of antibiotic

administration, and tourniquet

application.

of 44

Smoking cessation

-

I

Encourage smoking

cessation within 30 days

of procedure.

-

-

-

TOPICS WHO

2016

SHEA/IDSA

2014

CDC

(unpublished draft)

2014

NICE*

2008/2013

RCSI

2012

PREOPERATIVE

Preoperative infections

-

I

Identify and treat

infections (e.g. urinary

tract infection) remote

to the surgical

Site prior to elective

surgery. Do not

routinely treat

colonization or

contamination.

-

-

-

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Extended-spectrum beta-

lactamase colonization

No recommendation.

Due to the lack of evidence, the


recommendation.

TOPICS WHO

2016

SHEA/IDSA

2014

CDC

(unpublished draft)

2014

NICE*

2008/2013

RCSI

2012

PREOPERATIVE

Corticosteroid or

immunosuppressive

medication



The panel suggests not to

discontinue

immunosuppressive

medication prior to surgery

for the purpose of

preventing SSI.

III

Avoid

immunosuppressive

medication in the

perioperative period if

possible

No recommendation

can be made regarding the

perioperative management

of systemic corticosteroid

or other immunosuppressive

therapy for the prevention

of SSI in prosthetic joint

arthroplasty.

- -

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TOPICS WHO

2016

SHEA/IDSA

2014

CDC

(unpublished draft)

2014

NICE*

2008/2013

RCSI

2012

PREOPERATIVE

Nutrition




the administration of oral or

enteral multiple-nutrient

enhanced nutritional formulas


SSI in underweight patients

who undergo major surgical

operations.

I

Do not routinely delay

surgery to provide

parenteral nutrition.

Hypoalbuminemia:

no recommendation.

Although a noted risk

factor, do not delay

surgery for the use of

total parenteral

nutrition.

- - -

of 44

TOPICS WHO

2016

SHEA/IDSA

2014

CDC

(unpublished draft)

2014

NICE*

2008/2013

RCSI

2012

PREOPERATIVE

Mechanical bowel

preparation

Conditional

recommendation,

moderate quality of

evidence

Preoperative oral antibiotics

combined with mechanical

bowel preparation should be

used to reduce the risk of SSI in

adult patients undergoing



moderate quality of

evidence

Mechanical bowel preparation

alone (without administration of

- - - -

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oral antibiotics) should not be

used for the purpose of reducing

SSI in adult patients undergoing


TOPICS WHO

2016

SHEA/IDSA

2014

CDC

(unpublished draft)

2014

NICE*

2008/2013

RCSI

2012

PREOPERATIVE

Blood transfusion

-

II

Blood transfusions

increase the risk of SSI

by decreasing

macrophage function.

Reduce blood loss and

the need for blood

transfusion to the

greatest extent possible.

IB

Do not withhold transfusion

of necessary blood products

from surgical patients as a

means to prevent SSI.

No recommendation

can be made regarding the

perioperative management

of blood transfusions for the

prevention of SSI in

prosthetic joint arthroplasty.

-

-

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TOPICS WHO

2016

SHEA/IDSC

2014

CDC (unpublished

draft)

2014

NICE*

2008/2013

RCSI

2012

INTRAOPERATIVE

Surgical hand scrub/

preparation

Yes



Surgical hand preparation

should be performed using

either a suitable antimicrobial

soap and water or a suitable

alcohol-based hand rub before

donning sterile gloves.

Yes: II

Surgical scrub for

surgical team members.

Use appropriate

antiseptic agent to

perform preoperative

surgical scrub. For most

products, scrub the

hands and forearms for

2–5 minutes.

-

Yes

No new recommendation from

the

2008 guidelines.

The operating team should

wash their hands prior to the

first operation on the list using

an aqueous antiseptic surgical

solution with a single-use brush

or pick to clean the nails and

ensure that hands and nails are

visibly clean.

Before subsequent operations,

-

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hands should be washed using

either an alcohol-based hand

rub or an antiseptic surgical

solution. If hands are visibly

soiled, they should be cleansed

again with an antiseptic surgical

solution.

TOPICS WHO

2016

SHEA/IDSC

2014

CDC (unpublished

draft)

2014

NICE*

2008/2013

RCSI

2012

INTRAOPERATIVE

Skin antiseptic preparation

Yes

Strong recommendation, low

to moderate quality of

evidence

Alcohol-based antiseptic

solutions, in particular those

based on CHG, are

recommended for surgical site

skin preparation in patients

undergoing surgical

Yes: I

Wash and clean skin

around the incision site.

Use a dual agent skin

preparation containing

alcohol, unless

contraindications exist.

Yes: 1A

Perform intraoperative skin

preparation with an alcohol-

based antiseptic agent,

unless contraindicated.


made regarding the safety

and effectiveness of repeat

applications of antiseptic

agents to the patient’s skin

immediately prior to closing

Yes

Use povidone-iodine or CHG,

although alcohol-based

solutions may be more effective

than aqueous solutions.

The most effective antiseptic

for skin preparation before

surgical incision remains

uncertain.

Yes: 1A

Use CHG 2% chlorhexidine

gluconate in an isopropyl

70% alcohol solution for skin

preparation (if the patient is

sensitive/allergic, use

povidone-iodine)

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procedures. the surgical incision.

Normothermia

(temperature control)

Yes

Conditional

recommendation,

moderate quality of

evidence

The panel suggests the use

of warming devices in the

operating room and during

the surgical procedure for

patient body warming with

the purpose of reducing

SSI.

Yes: I

Maintain normothermia

(temperature of 35.5°C

or

more) during the

perioperative period.

Yes: 1A

Maintain perioperative

normothermia.



and effectiveness of

strategies to achieve and

maintain normothermia, the

lower limit of

normothermia, or the

optimal timing and duration

of normothermia.

-

Yes: 1A

Body temperature maintained

above 36°C in the

perioperative period (excludes

cardiac patients).

TOPICS WHO

2016

SHEA/IDSC

2014

CDC (unpublished

draft)

2014

NICE*

2008/2013

RCSI

2012

INTRAOPERATIVE

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Glucose control

(normoglycaemia)

Conditional

recommendation, low

quality of evidence.

We suggest the use of

protocols for intensive

perioperative blood glucose

control for both diabetic and

non-diabetic adult patients

undergoing surgical

procedures.

Yes: I

Control serum blood

glucose levels for all

surgical patients,

including patients

without diabetes. For

patients with diabetes

mellitus, reduce

glycosylated hemoglobin

A1c levels to less than

7% before surgery,,if

possible.

Yes: IA

Implement perioperative

glycaemic control and use

blood glucose target levels

<200 mg/dL in diabetic and

non-diabetic patients.



and effectiveness of lower

(<200 mg/dL ) or narrower

blood glucose target levels

or the optimal timing,

duration or delivery method

of perioperative glycaemic

control for the prevention of

SSI.


made regarding optimal

haemoglobin A1C target

levels for the prevention of

SSI in diabetic and non-

diabetic patients.

-

Yes: 1B

If the patient is diabetic, the

glucose level is kept at <11

mmol/L throughout the

operation

TOPICS WHO

2016

SHEA/IDSC

2014

CDC (unpublished

draft)

2014

NICE*

2008/2013

RCSI

2012

INTRAOPERATIVE

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Supplemented oxygen

therapy

Yes



Adult patients undergoing

general anaesthesia with

endotracheal intubation for

surgical procedures should

receive 80 % fraction of

inspired oxygen (FiO2) FiO2

of 80% intraoperatively and, if

feasible, in the immediate

postoperative period for 2-6

hours.

.

Yes: I

Optimize tissue

oxygenation by

administering

supplemental oxygen

during and immediately

following surgical

procedures involving

mechanical ventilation.

Yes: 1A

For patients with normal

pulmonary function

undergoing a general

anaesthetic with

endotracheal intubation,

administer an increased

FiO2 both intraoperatively

and post-extubation in the

immediate postoperative

period.

To optimize tissue oxygen

delivery, maintain

perioperative normothermia

and adequate volume

replacement.




administering perioperative

Yes

Perioperative oxygen

supplementation does not

appear to reduce SSI rates, but

more research is needed to

investigate subgroups of

patients for whom

supplemented oxygen could be

beneficial.

Yes: 1B

The patient’s haemoglobin

saturation is maintained

above 95% (or as high as

possible if there is underlying

respiratory insufficiency).

TOPICS WHO

2016

SHEA/IDSC

2014

CDC (unpublished

draft)

2014

NICE*

2008/2013

RCSI

2012

INTRAOPERATIVE

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increased FiO2 for the


patients with normal

pulmonary function

undergoing either general

anaesthesia without

endotracheal intubation or

neuraxial anaesthesia (i.e.

spinal, epidural, or local

nerve blocks).




administering increased

FiO2 via facemask or nasal

cannula only during the

postoperative period for the


patients with normal

pulmonary function.


made regarding the optimal

target level, duration and

delivery method of FiO2 for

the prevention of SSI.

TOPICS WHO

2016

SHEA/IDSC

2014

CDC (unpublished

draft)

2014

NICE*

2008/2013

RCSI

2012

INTRAOPERATIVE

of 44

Normovolemia

(adequate circulating volume

control)

Yes

Conditional

recommendation, low quality

of evidence.

The panel suggests the use of

intraoperative goal-directed

fluid therapy for the purpose of

reducing SSI.

-

- Haemodynamic goal-directed

therapy (titration of fluid and

inotropic drugs to reach normal

or supraoptimal physiological

endpoints, such as cardiac

output and oxygen delivery)

appears to reduce SSI rates.

-

Drapes and gowns of the

surgical field

Conditional

recommendation,

moderate to very low to

quality of evidence

The panel suggests that either

disposable non-woven or

reusable woven drapes and

surgical gowns can be used

during surgical operations for

the purpose of preventing SSI.

I

Do not routinely use

antiseptic drapes as a

strategy to prevent SSI.

II

Use of plastic adhesive

drapes with or without

antimicrobial properties is

not necessary for the

prevention of SSI.

- -

TOPICS WHO

2016

SHEA/IDSC

2014

CDC (unpublished

draft)

2014

NICE*

2008/2013

RCSI

2012

INTRAOPERATIVE

of 44


moderate to very low to quality

of evidence

The panel suggests not to use

plastic adhesive incise drapes

with or without antimicrobial

properties for the purpose of

preventing SSI.

Use of antimicrobial sutures Conditional recommendation,

low to moderate quality of

evidence


triclosan-coated sutures for the

purpose of reducing the risk of

SSI, independent of the type of

surgery.

II

Do not routinely use

antiseptic-

impregnated sutures

as a strategy to

prevent SSI.

II

Use of antimicrobial-coated

sutures is not necessary for


Antimicrobial-coated sutures

may reduce the SSI risk vs.

uncoated sutures, but this effect

may be specific to particular

types of surgery, e.g. abdominal

procedures.

-

TOPICS WHO

2016

SHEA/IDSC

2014

CDC (unpublished

draft)

2014

NICE*

2008/2013

RCSI

2012

INTRAOPERATIVE

of 44

Wound/tissue irrigation



There is insufficient evidence to

recommend for or against the

saline irrigation of incisional

wounds for the purpose of

preventing SSI..




the use of irrigation of the

incisional wound with an

aqueous povidone iodine solution


SSI, particularly in clean and

clean-contaminated wounds.



The panel suggests that antibiotic

incisional wound irrigation

should not be used for the

purpose of preventing SSI.

II

Perform antiseptic

wound lavage.

No recommendation




intraoperative antimicrobial

irrigation (e.g. intra-

abdominal, deep or

subcutaneous tissues) for


- -

TOPICS WHO

2016

SHEA/IDSC

2014

CDC (unpublished

draft)

2014

NICE*

2008/2013

RCSI

2012

INTRAOPERATIVE

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Wound protectors


very low quality of evidence.


the use of wound protector

devices in clean-contaminated,

contaminated and dirty abdominal

surgical procedures for the

purpose of reducing the rate of

SSI.

I

Use impervious

plastic wound

protectors (plastic

sheath) for

gastrointestinal and

biliary tract surgery.

- Wound-edge protection devices

may reduce SSI rates after open

abdominal surgery, but further

research is needed.

-

Change of instruments during

surgery

No recommendation

Due to the lack of evidence the


recommendation.

-

-

-

-

Use of antimicrobial sealants



The panel suggests that

antimicrobial sealants should not

be used after surgical site skin

preparation for the purpose of

reducing SSI.

-

II

Application of an

antimicrobial sealant

immediately following

intraoperative skin

preparation is not necessary

for the prevention of SSI.

-

-

TOPICS WHO

2016

SHEA/IDSC

2014

CDC (unpublished

draft)

2014

NICE*

2008/2013

RCSI

2012

INTRAOPERATIVE

of 44

Use of drains



The panel suggests that

preoperative antibiotic

prophylaxis should not be

continued due to the presence of a

wound drain for the purpose of

preventing SSI.



The panel suggests removing the

wound drain when clinically

indicated. No evidence was found

to allow making a

recommendation on the optimal

timing of wound drain removal

for the purpose of reducing SSI.

-

-

-

-

TOPICS WHO

2016

SHEA/IDSC

2014

CDC (unpublished

draft)

2014

NICE*

2008/2013

RCSI

2012

INTRAOPERATIVE

of 44

Prophylactic negative

pressure wound therapy




prophylactic negative pressure

wound therapy on primarily

closed surgical incisions in high-

risk wounds and, taking resources

into account, for the purpose of

preventing SSI..

- - Negative pressure wound

therapy appears to reduce SSI

rates after invasive treatment of

lower limb trauma, but may be

less effective in other patient

groups, such as those with

multiple comorbidities. Further

research is needed.

-

Use of gloves

No recommendation

Due to the lack of evidence to

assess whether double-gloving or

a change of gloves during the

operation or the use of specific

types of gloves are more effective

in reducing the risk of SSI, the


recommendation.

III

All members of the

operating team should

double-glove and

change gloves when

perforation is noted.

- - -

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TOPICS WHO

2016

SHEA/IDSC

2014

CDC (unpublished

draft)

2014

NICE*

2008/2013

RCSI

2012

POSTOPERATIVE

Surgical antibiotic

prophylaxis

prolongation in all types of

surgical procedures

No


moderate quality of

evidence

The panel recommends

against prolonging the

administration of antibiotics

after completion of the

operation for the purpose of

preventing SSI.

-

-

-

-

Postoperative wound dressing



The panel suggests not using any

type of advanced dressing on

primarily closed surgical wounds

for the purpose of preventing SSI.

-

No recommendation




antimicrobial dressings

applied to surgical incisions

following primary closure

in the operating room for


No recommendations

No particular dressing type

emerges as the most effective in

reducing the risk of SSI,

although silver nylon dressings

may be more effective than

gauze. Further research to

establish efficacy among

modern dressing types is

needed.

-

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TOPICS WHO

2016

SHEA/IDSC

2014

CDC (unpublished

draft)

2014

NICE*

2008/2013

RCSI

2012

POSTOPERATIVE

Soaking prosthetic devices in

antimicrobial solutions

- - No recommendation



and effectiveness of soaking

prosthetic devices in

antiseptic solutions prior to

implantation.

- -

Application of topical

antimicrobial agents

- - IB

Do not apply antimicrobial

agents (i.e. ointments,

solutions, powders) to the

surgical incision for the

prevention of SSI.

- -

Gentamicin-impregnated

sponge

-

-

- Limited evidence suggests that

a gentamicin-impregnated

sponge may reduce rates of

deep sternal wound infection

after cardiac surgery via median

sternotomy.

-

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TOPICS WHO

2016

SHEA/IDSC

2014

CDC (Draft)

2014

NICE*

2008/2013

RCSI

2012

Others

Education

Included in separate document on

implementation strategies

III

Educate surgeons and

perioperative

personnel about SSI

prevention.

III

Educate patients and

their families about

SSI prevention, when

appropriate.

- - -

Implement policies and

practices



II

Implement policies

and practices aimed at

reducing

the risk of SSI that

align with evidence-

based standards.

- - -

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TOPICS WHO

2016

SHEA/IDSC

2014

CDC (Draft)

2014

NICE*

2008/2013

RCSI

2012

Others

Ventilation of the operating

room (laminar flow)


low to very low quality of

evidence

The panel suggests that laminar

airflow ventilation systems

should not be used to reduce the

risk of SSI for patients

undergoing total arthroplasty

surgery.

III

Follow the American

Institute of Architects

recommendations for

proper air handling in

the operating room.

- - -

Adhere to principles of asepsis

- III

Adhere to standard

principles of operating

room asepsis.

- - -

Minimize operative time

- I

Minimize as much as

possible without

sacrificing surgical

technique and aseptic

practice.

- - -

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TOPICS WHO

2016

SHEA/IDSC

2014

CDC (Draft)

2014

NICE*

2008/2013

RCSI

2012

Others

Surgeon skill/technique

- III

Handle tissue carefully

and eradicate dead

space.

- -

Observe and review operating

room personnel

- III

Observe and review

operating room

personnel and the

care environment in

the operating room.

- - -

Traffic control



III

Minimize operating

room traffic.

- - -

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TOPICS WHO

2016

SHEA/IDSC

2014

CDC (Draft)

2014

NICE*

2008/2013

RCSI

2012

Others

Cleaning and decontamination

of environmental surfaces

Dedicated chapter but no

recommendation

III

Use an environmental

protection agency-

approved hospital

disinfectant to clean

visibly soiled or

contaminated surfaces

and equipment.

- - -

Sterilization of surgical

equipment

Dedicated chapter but no

recommendation

II

Sterilize all surgical

equipment according

to published

guidelines.

Minimize the use of

immediate-use steam

sterilization.

- - -

WHO surgical checklist



I

Use a checklist based

on the WHO checklist

to ensure compliance

with best practices to

improve surgical

patient safety.

- - -

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TOPICS WHO

2016

SHEA/IDSC

2014

CDC (Draft)

2014

NICE*

2008/2013

RCSI

2012

Others

SSI surveillance Dedicated chapter but no

recommendation

II

Perform surveillance

for SSI

- - -

SSI: surgical site infection; US: United States; UK: United Kingdom; EU: European Union; SHEA: Society for Healthcare Epidemiology of America; IDSA:

Infectious Diseases Society of America; NICE: National Institute for Clinical Excellence; RCSI: Royal College of Surgeons in Ireland; CDC: Centers fraction

of inspired oxygen.

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Table 1.2: Summary of surgical site care bundles

Preoperative

Perioperative Postoperative

Screening for

Staphylococcus

aureus

Perioperative

shower/bath

Avoid hair

removal

Prophylactic

antibiotic

Skin preparation

(antiseptics +

alcohol)

Normothermia Supplemented

oxygen

Glucose control Aseptic non-

touch technique

Surgical

dressing

Hand hygiene

USA Institute

of Health

Improvement

Surgical site

infection

- - Appropriate

hair removal.

Appropriate

use of

prophylactic

antibiotics.

- Immediate

postoperative

normothermia

in colorectal

surgery

- Controlled

postoperative

serum glucose in

cardiac surgery.

- - -

USA Institute

of Health

Improvement

Hip and knee

arthroplasty

Screen patients

for S. aureus (and

decolonize

carriers with 5

days of intranasal

mupirocin and

bathing or

showering CHG

soap for at least 3

days before

surgery.

Instruct patients

to bathe or

shower with

CHG soap for at

least 3 days

before surgery.

Appropriate

hair removal.

Appropriate

use of

prophylactic

antibiotics.

Use an alcohol-

containing

antiseptic agent

for preoperative

skin preparation.

- - - - -

UK High

impact

intervention

Patient has been

screened for

methicillin-

resistant S. aureus

(MRSA) using

local guidelines. If

found positive,

patients are

decolonized

according to the

recommended

protocol prior to

Patient has

showered (or

bathed/washed if

unable to shower)

preoperatively

using soap.

If hair removal

is required, it is

removed using

clippers with a

disposable

head (not by

shaving) and

timed as close

to the

operating

procedure as

Appropriate

antibiotics

were

administered

within 60

minutes prior

to incision and

only repeated

if there is

excessive

blood loss, a

prolonged

Patient’s skin

has been

prepared with

CHG 2% in an

isopropyl 70%

alcohol solution

and allowed to

air dry. (If the

patient has a

sensitivity to

CHG, a

povidone-iodine

Body

temperature is

maintained

above 36°C in

the peri-

operative

period.

Patients’

haemoglobin

saturation is

maintained above

95% (or as high

as possible if

there is

underlying

respiratory

insufficiency) in

the intra- and

postoperative

A glucose level of

<11 mmol/L is

maintained in

diabetic patients.

(This tight blood

glucose control

is not yet

considered

relevant in non-

diabetic patients.)

The principles of

asepsis (non-

touch technique)

are used when the

wound is being

redressed.

The wound is

covered with an

interactive

dressing at the

end of surgery

and while the

wound is

healing. The

interactive

wound dressing

is kept

undisturbed for

Hands are

decontaminated

immediately

before and after

each episode of

patient contact

using the correct

hand hygiene

technique. (Use

the WHO “5

moments for hand

hygiene” or

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CHG: chlorhexidine gluconate

surgery. possible. operation or

during

prosthetic

surgery.

application is

used.)

stages (recovery

room).

a minimum of

48 hours after

surgery unless

there is leakage

from the

dressing and

need for a

change.

according to the

National Patient

Safety Agency

“Cleanyourhands”

campaign is

recommended.)

Health

Protection

Scotland

A clinical risk

assessment for

MRSA screening

is undertaken.

The patient has

showered (or

bathed/washed if

unable to shower)

on day of or day

before surgery

using soap.

Hair is not

removed if at

all possible; if

hair removal is

necessary, do

not use razors.

Prophylactic

antibiotics are

prescribed as

per local

antibiotic

policy/Scottish

Intercollegiate

Guidelines

Network for

the specific

operation

category. The

antibiotic is

administered

within 60

minutes prior

to the

operation

(blade to

skin).

CHG 2% in an

isopropyl 70%

alcohol solution

is used for

skin preparation

(if the patient is

sensitive, use

povidone-

iodine).

Patient body

temperature is

maintained

above 36°C in

the

perioperative

period

(excludes

cardiac

patients).

Patient

haemoglobin

saturation is

maintained above

95% (or as high

as possible if

there is

underlying

respiratory

insufficiency).

Glucose level of

the diabetic

patient is kept at

<11mmol/L

throughout the

operation.

Aseptic technique

is used, if there is

excess wound

leakage and need

for

a dressing

change.

The wound is

covered with a

sterile wound

dressing at the

end of surgery.

The wound

dressing is kept

in place for 48

hours after

surgery unless

clinically

indicated.

Hand hygiene is

performed

immediately

before every

aseptic dressing

change (WHO –

“Moment 2”).

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