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New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective

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Summary

Surgical site infections (SSIs) are among the most preventable health-care-associated infections and are a substantial burden to health-care systems and service payers worldwide in terms of patient morbidity, mortality, and additional costs. SSI prevention is complex and requires the integration of a range of measures before, during, and after surgery. No international guidelines are available and inconsistencies in the interpretation of evidence and recommendations of national guidelines have been identified. Given the burden of SSIs worldwide, the numerous gaps in evidence-based guidance, and the need for standardisation and a global approach, WHO decided to prioritise the development of evidence-based recommendations for the prevention of SSIs. The guidelines take into account the balance between benefits and harms, the evidence quality, cost and resource use implications, and patient values and preferences. On the basis of systematic literature reviews and expert consensus, we present 13 recommendations on preoperative preventive measures.

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

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

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