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

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Summary

Surgical site infections (SSIs) are the most common health-care-associated infections in developing countries, but they also represent a substantial epidemiological burden in high-income countries. The prevention of these infections is complex and requires the integration of a range of preventive measures before, during, and after surgery. No international guidelines are available and inconsistencies in the interpretation of evidence and recommendations in national guidelines have been identified. Considering the prevention of SSIs as a priority for patient safety, WHO has developed evidence-based and expert consensus-based recommendations on the basis of an extensive list of preventive measures. We present in this Review 16 recommendations specific to the intraoperative and postoperative periods. The WHO recommendations were developed with a global perspective and they take into account the balance between benefits and harms, the evidence quality level, cost and resource use implications, and patient values and preferences.

Introduction

Surgical site infections (SSIs) are largely preventable, but they represent a considerable burden for health-care systems, particularly in low-income and middle-income countries. For these reasons, and the fact that no general set of international recommendations exists, WHO prioritised the development of evidence-based global guidelines for the prevention of SSIs. A panel of international experts developed recommendations on the basis of predetermined research questions and the results of related systematic literature reviews. The description of the intended audience for these recommendations, the methods used, and the first group of recommendations regarding preoperative preventive measures are provided in paper 1 of this Series,1 which should be read in conjunction with this Review. We present here the recommendations (table) to be applied in the intraoperative and postoperative periods. Important topics such as asepsis in the operating room and sterilisation are not mentioned because they were not the object of formal recommendations, but they are included and extensively reviewed in the WHO guidelines, as cornerstones of SSI prevention.

Section snippets

Recommendation 1: perioperative oxygenation

The panel recommends that adult patients undergoing general anaesthesia with endotracheal intubation for surgical procedures should receive an 80% fraction of inspired oxygen (FiO2) intraoperatively and, if feasible, in the immediate postoperative period for 2–6 h, to reduce the risk of SSI (strong recommendation, moderate quality of evidence).

Adequate surgical site tissue oxygenation is thought to have a role in preventing SSIs. A high partial pressure of oxygen in the blood achieved through

Recommendation 2: maintaining normal body temperature (normothermia)

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 (conditional recommendation, moderate quality of evidence).

Hypothermia is defined as a core temperature less than 36°C. It commonly occurs during and after surgical procedures lasting more than 2 h because of impairment of thermoregulation by anaesthesia, combined with exposure to a cold environment (the operating room).22, 23 Unintended

Recommendation 3: use of intensive protocols for perioperative blood glucose control

The panel suggests the use of protocols for intensive perioperative blood glucose control for both diabetic and non-diabetic adults undergoing surgical procedures, to reduce the risk of SSI (conditional recommendation, low quality of evidence).

A rise in blood glucose concentration is commonly observed in the operative and postoperative periods because of a surgical stress response, resulting in increased secretion of catabolic hormones (eg, catecholamines or cortisol), inhibition of insulin

Recommendation 4: maintenance of adequate circulating volume control (normovolaemia)

The panel suggests the use of goal-directed fluid therapy (GDFT) intraoperatively to reduce the risk of SSI (conditional recommendation, low quality of evidence).

Adequate intravascular volume is an essential component of tissue perfusion and an important aspect of tissue oxygenation.53 In unbalanced fluid states—ie, hypovolaemia and hypervolaemia—tissue oxygenation is compromised and might increase the risk of SSI.54 The optimal type of fluid (colloid or crystalloid) or strategy of fluid

Recommendations 5 and 6: drapes and gowns

The panel suggests that either sterile disposable non-woven or sterile reusable woven drapes and surgical gowns be used during surgical operations for the purpose of preventing SSI (conditional recommendation, moderate to very low quality of evidence); and suggests that plastic adhesive incise drapes with or without antimicrobial properties should not be used (conditional recommendation, low to very low quality of evidence).

Drapes and gowns are available for single-use or multiple-use, with

Recommendation 7: 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 SSIs (conditional recommendation, very low quality of evidence).

Wound-protector devices (or wound-edge protectors) are comprised of a non-adhesive plastic sheath attached to a single or double rubber ring that firmly secures the sheath to the wound edges. They facilitate the retraction of the incision during

Recommendations 8 and 9: incisional wound irrigation

The panel suggests considering the use of irrigation of the incisional wound with an aqueous povidone-iodine solution before closure for the purpose of preventing SSI, particularly in clean and clean-contaminated wounds (conditional recommendation, low quality of evidence); but the panel suggests that antibiotic incisional wound irrigation before closure should not be done (conditional recommendation, low quality of evidence); insufficient evidence was available to recommend for or against

Recommendation 10: prophylactic negative-pressure wound therapy

The panel suggests the use of prophylactic negative-pressure wound therapy (pNPWT) on primarily closed surgical incisions in high-risk wounds, for the purpose of preventing SSI, while taking resources into account (conditional recommendation, low quality of evidence).

pNPWT consists of a closed sealed system connected to a vacuum pump, which maintains negative pressure on the wound surface. Although used for several other purposes since the late 1990s, it is also applied on primarily closed

Recommendation 11: antimicrobial-coated sutures

The panel suggests the use of triclosan-coated sutures to reduce the risk of SSIs, independent of the type of surgery (conditional recommendation, moderate quality of evidence).

Sutures with antimicrobial properties were developed with the aim to prevent microbial colonisation of the suture material in operative incisions. Early studies showed a reduction of the number of bacteria in vitro and wound infections in animals145, 146, 147 using triclosan-coated sutures and this effect was

Recommendation 12: laminar airflow ventilation systems in the context of operating room ventilation

The panel suggests that laminar airflow ventilation systems should not be used to reduce the risk of SSIs for patients undergoing total arthroplasty surgery (conditional recommendation, low to very low quality of evidence).

Conventional ventilation systems pass air with a mixed or turbulent flow into the operating room. These systems aim to homogenise the fresh air, the air, and aerosols and particles within the room. Laminar airflow systems pass the fresh air unidirectionally with a steady

Recommendations 13 and 14: antimicrobial prophylaxis in the presence of a drain and optimal timing for wound drain removal

The panel suggests not continuing perioperative antibiotic prophylaxis because of the presence of a wound drain (conditional recommendation, low quality of evidence). They also suggest removing the wound drain when clinically indicated, but they found no evidence to recommend an optimal time for wound drain removal (conditional recommendation, very low quality of evidence).

Drainage tubes are widely used in surgery to remove any fluid or blood that collects in the wounds and cavities created by

Recommendation 15: wound 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 SSIs (conditional recommendation, low quality of evidence).

A wide variety of wound dressings are available. Advanced dressings are mainly hydrocolloid, hydrogels, fibrous hydrocolloid, or polyurethane matrix hydrocolloid dressings and vapour-permeable films. A Cochrane review195 and its update196 on the effect of dressings for the prevention of

Recommendation 16: postoperative surgical antibiotic prophylaxis prolongation

The panel recommends against the prolongation of surgical antibiotic prophylaxis (SAP) administration after completion of the operation for the purpose of preventing SSIs (strong recommendation, moderate quality of evidence).

The preventive effect of the routine use of SAP has long been recognised; however, the necessary duration of SAP to achieve the desired effect has been a matter of debate. Most guidelines recommend a maximum postoperative SAP duration of 24 h, but increasing evidence shows

Conclusion

We discuss the evidence for a broad range of intraoperative and postoperative preventive measures identified by an expert panel as potentially contributing to reducing the risk of SSI. For some of these, the evidence shows no benefit and the 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

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