For each population, intervention, comparator, outcomes question, we searched MEDLINE (PubMed or Ovid), Embase, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Central Register of Controlled Trials, and WHO regional medical databases, to identify relevant articles. The time limit was January, 1990, and the systematic reviews were done between December, 2013, and December, 2015. Studies in English, French, and Spanish were eligible; but some reviews were not restricted by
SeriesNew WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective
Introduction
Health-care-associated infections are avoidable infections that affect hundreds of millions of people each year worldwide. Following a systematic review of the literature and meta-analyses, WHO reported in 2010 that the prevalence of health-care-associated infections in low-income and middle-income countries (LMICs) was two to 20 times higher than in high-income countries.1, 2, 3 Surgical site infection (SSI) was the most surveyed and most frequent health-care-associated infection in LMICs, affecting up to a third of patients who had surgery. The incidence of SSI is much lower in high-income countries, but it is still the second most common cause of health-care-associated infection in Europe and the USA.1, 4 Furthermore, data from the USA showed that up to 60% of the microorganisms isolated from infected surgical wounds have antibiotic resistance patterns.5
Considering the epidemiological importance of SSIs, and the fact that these infections are largely preventable, WHO decided to prioritise the development of evidence-based recommendations for the prevention of SSIs. Many factors in the patient's journey through surgery contribute to the risk of SSI, and prevention is complex and requires the integration of a range of measures before, during, and after surgery. Further strong reasons to develop global guidelines on this topic include the absence of any international guidance document and inconsistencies in the interpretation of the evidence and strength of recommendations in national guidelines. We present the WHO recommendations for measures to be implemented or initiated during the preoperative period. These were elaborated according to the best available scientific evidence and expert consensus with the aim to ensure high-quality care for every patient, irrespective of the resources available. Important topics such as SSI surveillance are not mentioned in this Review because formal recommendations have not been made, but they are extensively reviewed in the WHO guidelines as cornerstones of SSI prevention. The intended audience for these recommendations is primarily the surgical team (ie, surgeons, nurses, technical support staff, anaesthetists, and any professionals directly providing surgical care), infection prevention and control professionals, policymakers, senior managers, and hospital administrators. People responsible for staff education and training are also key stakeholders and implementers.
Section snippets
Data gathering
We developed the WHO guidelines following the standard methods described in the WHO handbook for guideline development.6 We identified and formulated key research questions on priority topics for SSI prevention according to the Population, Intervention, Comparator, Outcomes process,7 on the basis of expert opinion. SSI and SSI-attributable mortality were the primary outcomes for all research questions. We did targeted systematic literature reviews and reported the results according to the
Recommendation 1: perioperative discontinuation of immunosuppressive agents
The panel suggests not to discontinue immunosuppressive medication before surgery to prevent SSI (conditional recommendation, very low quality of evidence).
Immunosuppressive agents commonly used for preventing the rejection of transplanted organs or for the treatment of inflammatory diseases could lead to impaired wound healing and an increased risk of infection in patients administered these agents.14 By contrast, the discontinuation of immunosuppressive treatment could induce flares of
Recommendation 2: enhanced nutritional support
The panel suggests considering the administration of oral or enteral multiple nutrient-enhanced nutritional formulas to prevent SSI in underweight patients who undergo major surgical operations (conditional recommendation, very low quality of evidence).
The nutritional status of patients can lead to alterations in host immunity that can make them more susceptible to postoperative infections. Early nutritional support can improve the outcome of major surgery and decrease the incidence of
Recommendation 3: preoperative bathing
Good clinical practice requires that patients bathe or shower before surgery. The panel suggests that either a plain or antimicrobial soap can be used for this purpose (conditional recommendation, moderate quality of evidence).
Preoperative whole-body bathing or showering is considered to be good clinical practice to ensure that the skin is as clean as possible before surgery and reduce the bacterial load, particularly at the site of incision. In general, an antiseptic soap is used in settings
Recommendations 4 and 5: decolonisation with mupirocin ointment with or without chlorhexidine gluconate body wash in nasal carriers undergoing surgery
The panel recommends that patients undergoing cardiothoracic and orthopaedic surgery who are known nasal carriers of Staphylococcus aureus, should receive perioperative intranasal applications of mupirocin 2% ointment with or without a combination of chlorhexidine gluconate body wash (strong recommendation, moderate quality of evidence). The panel suggests considering the use of the same treatment in patients with known nasal carriage of S aureus undergoing other types of surgery (conditional
Recommendations 6 and 7: mechanical bowel preparation and the use of oral antibiotics
The panel suggests that preoperative oral antibiotics combined with mechanical bowel preparation (MBP) should be used to reduce the risk of SSI in adult patients undergoing elective colorectal surgery (conditional recommendation, moderate quality evidence), and recommends that MBP alone (without administration of oral antibiotics) should not be used (strong recommendation, moderate quality evidence).
MBP involves the preoperative administration of substances (polyethylene glycol and sodium
Recommendation 8: hair removal
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 operating room (strong recommendation, moderate quality of evidence).
Removal of hair from the intended site of surgical incision has traditionally been part of the routine preoperative preparation of patients. Hair is perceived to be
Recommendations 9 and 10: optimal timing for administration of surgical antibiotic prophylaxis (SAP)
The panel recommends the administration of SAP before surgical incision when indicated, depending on the type of operation (strong recommendation, low quality of evidence); it should be done within the 120 min before the incision, while considering the half-life of the antibiotic (strong recommendation, moderate quality of evidence).
SAP refers to the prevention of infectious complications by administering an antimicrobial agent before exposure to contamination during surgery.100 Successful SAP
Recommendation 11: surgical hand preparation
The panel recommends that surgical hand preparation be done either by scrubbing with a suitable antimicrobial soap and water or using a suitable alcohol-based hand rub (ABHR) before donning sterile gloves (strong recommendation, moderate quality of evidence).
Surgical hand preparation (figure) is vitally important to maintain the least possible contamination of the surgical field, especially in the case of sterile glove puncture during the procedure. Appropriate surgical hand preparation is
Recommendation 12: surgical site skin preparation
The panel recommends alcohol-based antiseptic solutions that are based on chlorhexidine gluconate for surgical site skin preparation in patients undergoing surgical procedures (strong recommendation, low to moderate quality of evidence).
The aim of surgical site skin preparation is to reduce the microbial load on the patient's skin as much as possible before incision of the skin barrier. The most common agents include chlorhexidine gluconate and povidone-iodine in alcohol-based solutions, but
Recommendation 13: antimicrobial skin sealants
The panel suggests that antimicrobial sealants should not be used after surgical site skin preparation for the purpose of reducing SSI (conditional recommendation, very low quality of evidence).
Antimicrobial skin sealants are sterile, film-forming cyanoacrylate-based sealants commonly applied as an additional antiseptic measure after using standard skin preparation on the surgical site and before skin incision. They are intended to remain in place and block the migration of flora from the
Conclusion
We have discussed the evidence for a broad range of preventive measures identified by an expert panel that potentially contribute to reducing the risk of SSI occurrence. For some of these, the evidence shows no benefit and the expert panel advises against the adoption of these interventions, particularly when considering resource implications or other consequences, such as antimicrobial resistance. However, the panel identified a range of key measures for SSI prevention to be implemented in the
Search strategy and selection criteria
References (148)
- et al.
Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis
Lancet
(2011) - et al.
GRADE guidelines: 3. Rating the quality of evidence
J Clin Epidemiol
(2011) - et al.
GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables
J Clin Epidemiol
(2011) - et al.
Reduced infections with perioperative immunonutrition in head and neck cancer: exploratory results of a multicenter, prospective, randomized, double-blind study
Clin Nutr
(2014) - et al.
A randomized controlled trial of preoperative oral supplementation with a specialized diet in patients with gastrointestinal cancer
Gastroenterology
(2002) - et al.
The immunomodulating enteral nutrition in malnourished surgical patients—a prospective, randomized, double-blind clinical trial
Clin Nutr
(2011) - et al.
Effect of preoperative oral immune-enhancing nutritional supplement on patients at high risk of infection after cardiac surgery: a randomised placebo-controlled trial
Lancet
(2001) - et al.
Cost-effectiveness analysis of the use of chlorhexidine detergent in preoperative whole-body disinfection in wound infection prophylaxis
J Hosp Infect
(1992) A placebo-controlled trial of the effect of two preoperative baths or showers with chlorhexidine detergent on postoperative wound infection rates
J Hosp Infect
(1988)- et al.
Do preoperative chlorhexidine baths reduce the risk of infection after vascular reconstruction?
Eur J Vasc Surg
(1989)
Preoperative whole body disinfection—a controlled clinical study
J Hosp Infect
A comparison of pre-operative bathing with chlorhexidine-detergent and non-medicated soap in the prevention of wound infection
J Hosp Infect
Total body bathing with ‘Hibiscrub' (chlorhexidine) in surgical patients: a controlled trial
J Hosp Infect
Effectiveness of 2% CHG cloth bathing for reducing surgical site infections
AORN J
Preoperative chlorhexidine preparation and the incidence of surgical site infections after hip arthroplasty
J Arthroplasty
Impact of treating Staphylococcus aureus nasal carriers on wound infections in cardiac surgery
J Hosp Infect
Mechanical bowel preparation for elective colorectal surgery: a multicentre randomised trial
Lancet
Comparison between oral antibiotics and probiotics as bowel preparation for elective colon cancer surgery to prevent infection: prospective randomized trial
Surgery
Re: Nonshaved cranial surgery in black Africans: a short-term prospective preliminary study (Adeleye and Olowookere, Surg Neurol 2008; 69–72) Effect of hair on surgical wound infection after cranial surgery: a 3-armed randomized clinical trial
Surg Neurol
Preoperative hair removal on the male genitalia: clippers vs razors
J Sex Med
Wound infections after preoperative depilatory versus razor preparation
Am J Surg
Report on the burden of endemic health care-associated infection worldwide
Health-care-associated infection in Africa: a systematic review
Bull World Health Organ
Point prevalence survey of healthcare-associated infections and antimicrobial use in European acute care hospitals
Multistate point-prevalence survey of health care-associated infections
N Engl J Med
WHO handbook for guideline development
Evaluation of PICO as a knowledge representation for clinical questions
AMIA Annu Symp Proc
The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration
BMJ
The Cochrane Collaboration's tool for assessing risk of bias in randomised trials
BMJ
The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses
New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective
Lancet Infect Dis
Continuation of TNF blockade in patients with inflammatory rheumatic disease. An observational study on surgical site infections in 1,596 elective orthopedic and hand surgery procedures
Acta Orthop
Immunosuppressive therapy does not increase operative morbidity in patients with Crohn's disease
J Clin Gastroenterol
Influence of methotrexate on the frequency of postoperative infectious complications in patients with rheumatoid arthritis
J Rheumatol
Methotrexate and early postoperative complications in patients with rheumatoid arthritis undergoing elective orthopaedic surgery
Ann Rheum Dis
Should methotrexate be discontinued before elective orthopedic surgery in patients with rheumatoid arthritis?
J Rheumatol
Postoperative joint infections in rheumatoid arthritis patients on methotrexate therapy
Orthopedics
Early postoperative complications are not increased in patients with Crohn's disease treated perioperatively with infliximab or immunosuppressive therapy
Am J Gastroenterol
Risk factors for surgical site infections and other complications in elective surgery in patients with rheumatoid arthritis with special attention for anti-tumor necrosis factor: a large retrospective study
J Rheumatol
Lack of increase in postoperative complications with low-dose methotrexate therapy in patients with rheumatoid arthritis undergoing elective orthopedic surgery
Mod Rheumatol
Complications of pancreatic surgery and the role of perioperative nutrition
Dig Surg
Malnutrition in the twenty-first century: an epidemic affecting surgical outcome
Surg Infect (Larchmt)
The role of immunonutrition in gynecologic oncologic surgery
Eur J Gynaecol Oncol
Prospective randomized trial of preoperative enteral immunonutrition followed by elective total gastrectomy for gastric cancer
Br J Surg
Reduced postoperative infections with an immune-enhancing nutritional supplement
Laryngoscope
Glycine does not add to the beneficial effects of perioperative oral immune-enhancing nutrition supplements in high-risk cardiac surgery patients
JPEN J Parenter Enteral Nutr
Favorable effects of preoperative enteral immunonutrition on a surgical site infection in patients with colorectal cancer without malnutrition
Surg Today
Clinical significance of perioperative immunonutrition for patients with esophageal cancer
World J Surg
Immunoenhanced enteral nutrition formulas in head and neck cancer surgery: a prospective, randomized clinical trial
Nutr Hosp
Postsurgery enteral nutrition in head and neck cancer patients
Eur J Clin Nutr
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Members of the WHO Guidelines Development Group are listed at the end of the paper