The World Health Organization (WHO) has released the first international evidence-based guidelines for the prevention of surgical site infection (SSI).

The guidelines come against the backdrop of increasing antimicrobial resistance, and include 29 recommendations- 13 for the period before surgery, and 16 for preventing infections during and after surgery.

Background Information:

Surgical site infections are caused by bacteria that get in through incisions made during surgery. They threaten the lives of millions of patients each year and contribute to the spread of antibiotic resistance.

In low- and middle-income countries, 11% of patients who undergo surgery are infected in the process.

In Africa, up to 20% of women who have a caesarean section contract a wound infection, compromising their own health and their ability to care for their babies.

In the United States, they contribute to patients spending more than 400 000 extra days in hospital at a cost of an additional US$ 900 million per year.

The new WHO guidelines are valid for any country and suitable to local adaptations, and take account of the strength of available scientific evidence, the cost and resource implications, and patient values and preferences.

They complement WHO’s popular “Surgical Safety Checklist”, which gives a broad range of safety measures, by giving more detailed recommendations on preventing infections.

Key Recommendations:

I. Preoperative measures

A. Preoperative bathing

• It is good clinical practice for patients to bathe or shower prior to surgery. The panel suggests that either plain soap or an antimicrobial soap may be used for this purpose.

B. Decolonization with mupirocin ointment with or without Chlorhexidine gluconate (CHG) body wash for the prevention of Staphylococcus aureus infection in nasal carriers

• 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.
• 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.

C. Screening of Extended Spectrum Beta Lactamase (ESBL) colonization and the impact on antibiotic prophylaxis 

• No recommendation due to lack of evidence

D. Optimal timing for preoperative Surgical Antibiotic Prophylaxis (SAP)

• SAP should be administered prior to the surgical incision when indicated (depending on the type of operation).
• The panel recommends the administration of SAP within 120 minutes before incision, while considering the half-life of the antibiotic.

E. Mechanical bowel preparation and the use of oral antibiotics

• Preoperative oral antibiotics combined with mechanical bowel preparation should be used to reduce the risk of SSI in adult patients undergoing elective colorectal surgery.
• The panel recommends that 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.

F. Hair removal

1. The panel recommends that in patients undergoing any surgical procedure, hair should either not be removed or, if absolutely necessary, it should be removed only with a clipper. Shaving is strongly discouraged at all times, whether preoperatively or in the OR.

G. Surgical site preparation

• The panel recommends alcohol-based antiseptic solutions based on CHG for surgical site skin preparation in patients undergoing surgical procedures.

H. Antimicrobial skin sealants

• The panel suggests that antimicrobial sealants should not be used after surgical site skin preparation for the purpose of reducing SSI.

I. Surgical hand preparation

• Surgical hand preparation should be performed by scrubbing with either a suitable antimicrobial soap and water or using a suitable alcohol-based hand-rub before donning sterile gloves.

J. Maintaining normal body temperature (normothermia)

• The panel suggests the use of warming devices in the OR and during the surgical procedure for patient body warming with the purpose of reducing SSI.

K. Use of protocols for intensive perioperative blood glucose control

• The panel suggests the use of protocols for intensive perioperative blood glucose control for both diabetic and non-diabetic adult patients undergoing surgical procedures to reduce the risk of SSI.

L. Maintenance of adequate circulating volume control/ normovolemia

• The panel suggests the use of goal-directed fluid therapy intraoperatively to reduce the risk of SSI.

M. Drapes and gowns

• The panel suggests that either sterile, disposable non-woven or sterile, reusable woven drapes and gowns can be used during surgical operations for the purpose of preventing SSI.
• The panel suggests not to use plastic adhesive incise drapes with or without antimicrobial properties for the purpose of preventing SSI.

N. Wound protector devices

• The panel suggests considering the use of wound protector devices in clean-contaminated, contaminated and dirty abdominal surgical procedures for the purpose of reducing the rate of SSI.

O. Incisional wound irrigation

• There is insufficient evidence to recommend for or against saline irrigation of incisional wounds before closure for the purpose of preventing SSI.
• The panel suggests considering the use of irrigation of the incisional wound with an aqueous PVP-I solution before closure for the purpose of preventing 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.

P. Prophylactic negative pressure wound therapy 

• The panel suggests the use of prophylactic negative pressure wound therapy in adult patients on primarily closed surgical incisions in high-risk wounds for the purpose of the prevention of SSI, while taking resources into account.

Q. Use of surgical gloves

• The panel decided not to formulate a 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.

R. Changing of surgical instruments

• No recommendation due to lack of evidence

S. Antimicrobial -coated sutures

• The panel suggests the use of triclosan-coated sutures for the purpose of reducing the risk of SSI, independent of the type of surgery

T. Laminar flow ventilation systems in the context of OR ventilation

• Laminar airflow ventilation systems should not be used to reduce the risk of SSI for patients undergoing total arthroplasty surgery.

II. Preoperative and/or intraoperative measures 

A. Enhanced nutritional support

• The panel suggests considering 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.

B. Perioperative discontinuation of immunosuppressive agents

• The panel suggests not to discontinue immunosuppressive medication prior to surgery for the purpose of preventing SSI.

C. Perioperative oxygenation

• Adult patients undergoing general anaesthesia with endotracheal intubation for surgical procedures should receive an 80% fraction of inspired oxygen intraoperatively and, if feasible, in the immediate postoperative period for 2-6 hours to reduce the risk of SSI.

III. Postoperative measures

A. SAP prolongation

• The panel recommends against the prolongation of SAP after completion of the operation for the purpose of preventing SSI.

B. Advanced dressings

• The panel suggests not using any type of advanced dressing over a standard dressing on primarily closed surgical wounds for the purpose of preventing SSI.

C. Antimicrobial prophylaxis in the presence of a drain and optimal timing for wound drain removal 

• Preoperative antibiotic prophylaxis should not be continued in the presence of a wound drain for the purpose of preventing SSI.
• The panel suggests removing the wound drain when clinically indicated.

Useful Links:

Link to the WHO press release:

http://www.who.int/mediacentre/news/releases/2016/recommendations-surgical-infections/en/

Link to the Guidelines (English) [PDF]:

http://www.who.int/gpsc/global-guidelines-web.pdf?ua=1

Link to WHO’s infographic on preventing SSIs [PDF]:

http://www.who.int/gpsc/ssi-infographic.pdf?ua=1

Link to The European Centres for Disease Control’s (ECDC’s) latest report on SSIs:

http://ecdc.europa.eu/en/healthtopics/Healthcare-associated_infections/surgical-site-infections/Pages/Annual-epidemiological-report-2016.aspx

Link to WHO page containing Questions and Answers on SSIs:

http://www.who.int/gpsc/ssi-questions-answers/en/

Link to WHO document ‘Decontamination and Reprocessing of Medical Devices for Health-care Facilities’ (English)[PDF]:

http://apps.who.int/iris/bitstream/10665/250232/1/9789241549851-eng.pdf?ua=1