Recent guidelines to prevent surgical site infection

1. SURGICAL SITE
INFECTION –
RECENT
GUIDELINES
Dr Meenakshi
Sharma
MD(AIIMS), FICMCH, FICOG
Senior Consultant Obs &
Gynae
Yashoda Superspeciality
Hospital, Kaushambi
Shanti Mukund Hospital

2. GUIDELINES
Global guidelines for the prevention of surgical site
infection, WHO 2018
NICE guidelines 2019
ACOG 2018
FOGSI Consensus statement on cesarean section
2014 and FOGSI Focus 2018

3. BURDEN OF SSI
 SSI cumulative Incidence 2.9% in C section in
2010-2011, in Europe,
 Pooled Incidence of SSI - 6.3-9.3% on South east
Asia
 Pooled SSI after LSCS by WHO – 11.7%
 17% decrease in SSI in 10 surgical procedures in
five years
 In the USA, 39-51% SSI pathogens are resistant to
standard prophylactic antibiotics.
Global Guidelines for the Prevention of Surgical Site Infection –
WHO 2018

5. DEFINITION
Surgical site infection - an infection that occurs
within 30 days after the operation (90 days for
deep/ organ space) and involves the skin and
subcutaneous tissue of the incision (superficial
incisional) and/or the deep soft tissue (for
example, fascia, muscle) of the incision (deep
incisional) and/or any part of the anatomy (for
example, organs and spaces) other than the
incision that was opened or manipulated during
an operation (organ/space).
(Source: European Centre for Disease Prevention and
Control.
http://ecdc.europa.eu/en/publications/Publications/120
215_TED_SSI_protocol.pdf, accessed 21 February 2018.)

7. Clean Surgery
No break in skin and
sterile technique.
No GIT, GUT or
respiratory tract
entered
Clean
Contaminated
Surgery
GIT, GUT or respiratory
tract entered but no
contamination
Contaminated Surgery
Major break in sterile technique
or gross
spillage from the gastrointestinal
tract, or an incision in which
acute, non-purulent
inflammation is encountered
Open traumatic wounds that are
more than 12 to 24 hours old
Dirty/Infected wound
Conditions in which viscera are
perforated or when acute
inflammation with pus is
encountered (eg. emergency
surgery for faecal peritonitis),
or faecal contamination, or
devitalised tissue is present
Traumatic wounds if treatment
is delayed,
Types of Surgery

10. PREOPERATIVE –
BATHINGIt 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. (Conditional, Moderate)
Global Guidelines for the Prevention of Surgical Site Infection –
WHO 2018
NICE 2019
Patient should have bath with Chlorhexidine
instead of soap
ACOG 2018

11. 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, Moderate)
Global Guidelines for the Prevention of Surgical Site Infection –
WHO 2018
NICE 2019

12. MECHANICAL BOWEL
PREPARATION AND
THE USE OF ORAL
ANTIBIOTICSThe panel suggests that preoperative oral
antibiotics combined with mechanical bowel
preparation should be used to reduce the risk
of SSI in adult patients undergoing elective
colorectal surgery. (Conditional, Moderate)
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. (Strong,
Moderate)
Global Guidelines for the Prevention of Surgical Site Infection –
WHO 2018

13. SURGICAL SITE &
HAND PREPARATION
The panel recommends alcohol-based antiseptic
solutions based on CHG for surgical site skin
preparation in patients undergoing surgical
procedures. (Strong, low to moderate)
The panel recommends that surgical hand
preparation should be performed by scrubbing with
either a suitable antimicrobial soap and water or
using a suitable alcohol-based handrub before
donning sterile gloves. (Strong, Moderate)
Global Guidelines for the Prevention of Surgical Site Infection –
WHO 2018

14. SURGICAL SITE
PREPARATION
Pre-op abdominal skin preparation is preferably
done with alcohol-based preparations, and
chlorhexidine-alcohol was significantly more
effective than a povidone-iodine scrub in
preventing superficial and deep incisional infection.
Vaginal cleaning before surgery –Only PVP-I is FDA
approved
Chlorhexidine gluconate with high alcohol
concentration (70% isopropyl alcohol) is
contraindicated for vaginal preperation
Screen and treat for Bacterial vaginosis
preoperatively
ACOG2018

15. 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. (Conditional.
Low)
Global Guidelines for the Prevention of Surgical Site Infection –
WHO 2018

16. 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. (Conditional, Low)
Global Guidelines for the Prevention of Surgical Site
Infection – WHO 2018

17. 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. (Conditional, Moderate to low)
The panel suggests not to use plastic adhesive incise
drapes with or without antimicrobial properties for the
purpose of preventing SSI.(Conditional, low)
Global Guidelines for the Prevention of Surgical Site Infection – WHO
2018
Do not use non-iodophor-impregnated incise drapes
routinely for surgery as they may increase the risk of
surgical site infection.
If an incise drape is required, use an iodophor-
impregnated drape unless the patient has an iodine
allergy.

18. SURGICAL INCISION
Do not use diathermy for surgical
incision to reduce the risk of surgical
site infection.
NICE 2019

19. INCISIONAL WOUND
IRRIGATION
The panel considered that 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. (Conditional, Low)
Global Guidelines for the Prevention of Surgical Site Infection – WHO
2018
Only apply an antiseptic or antibiotic to the wound before
wound closure as part of a clinical research trial
NICE 2019

20. 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. (Conditional,
Low)
Global Guidelines for the Prevention of Surgical Site Infection –
WHO 2018
NICE 2019

21. SURGICAL
ANTIBIOTIC
PROPHYLAXISOptimal timing for preoperative SAP
The panel recommends the administration of SAP within
120 minutes before incision, while considering the half-
life of the antibiotic. (Strong, Moderate)
Global Guidelines for the Prevention of Surgical Site Infection – WHO
2018
Give a repeat dose of antibiotic prophylaxis when the
operation is longer than the half-life of the antibiotic
given.
Use the local antibiotic formulary and always take into
account the potential adverse effects when choosing
specific antibiotics for prophylaxis.
NICE 2019
In cases of long surgical procedures (> 4 hours) or blood

22. FOGSI Focus Surgical skills in Obstetrics and Gynaecology,
2018

23. FOGSI Focus Surgical skills in Obstetrics and
Gynaecology, 2018

24. SAP PROLONGATION
The panel recommends against the
prolongation of SAP after completion of the
operation for the purpose of preventing SSI.
(Strong, Moderate)
Global Guidelines for the Prevention of Surgical Site
Infection – WHO 2018

26. 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. (Conditional. Low)
Global Guidelines for the Prevention of Surgical Site
Infection – WHO 2018

27. ANTIMICROBIAL PROPHYLAXIS IN
THE PRESENCE OF A DRAIN AND
OPTIMAL TIMING FOR WOUND
DRAIN REMOVAL
The panel suggests that 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. No evidence was found to
allow making a recommendation on the optimal
timing of wound drain removal for the purpose of
preventing SSI.
(Conditional, Low)
Global Guidelines for the Prevention of Surgical Site
Infection – WHO 2018

28. WOUND
MANAGEMENT AFTER
SURGERYChanging dressings
Use an aseptic non-touch technique for changing or
removing surgical wound dressings.
Postoperative cleansing
Use sterile saline for wound cleansing up to 48 hours
after surgery.
Advise patients that they may shower safely 48 hours
after surgery.
Use tap water for wound cleansing after 48 hours if the
surgical wound has separated or has been surgically
opened to drain pus.
Do not use topical antimicrobial agents for surgical
wounds that are healing by primary intention to reduce
the risk of surgical site infection.

29. DRESSINGS FOR
WOUND HEALING BY
SECONDARY
INTENTIONDo not use Eusol and gauze, or moist cotton gauze
or mercuric antiseptic solutions to manage surgical
wounds that are healing by secondary intention.
Use an appropriate interactive dressing to manage
surgical wounds that are healing by secondary
intention.
NICE 2019