Surgical site infection - Recent Guidelines

Recent guidelines to prevent surgical site infection

1. Surgical Site Infection – Recent guidelines Dr M eenakshi 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

4. 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/120215_TED_SSI_protocol.pdf, accessed 21 February 2018.)

5. 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

6. 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. (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

7. 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

8. Mechanical bowel preparation and the use of oral antibiotics The 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

9. 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

10. 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

11. 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

12. 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

13. 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. NICE 2019

14. Surgical Incision Do not use diathermy for surgical incision to reduce the risk of surgical site infection. NICE 2019

15. 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

16. 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

17. Surgical Antibiotic Prophylaxis Optimal 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 loss > 1500 ml, repeat SAP ACOG 2018

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

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

20. 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

21. 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

22. 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

23. 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 . NICE 2019

24. Dressings for wound healing by secondary intention Do 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

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