WHO releases recommendations for preventing SSIs

Issue: December 2016

WHO has released the first international, evidence-based recommendations for preoperative, intraoperative and postoperative infection prevention. To reduce the risk for antibiotic resistance, the guidelines recommend only to use antibiotics before and during surgery — not afterward, as is often done.

“Most guidelines recommend a maximum postoperative [surgical antibiotic prophylaxis (SAP)] duration of 24 [hours], but increasing evidence shows that using only a single preoperative dose (and possible additional intraoperative doses according to the duration of the operation) might be noninferior,” Benedetta Allegranzi, MD, of WHO’s Infection Prevention and Control Global Unit, and colleagues wrote. “Despite this, surgeons still often routinely continue SAP up to several days after surgery, which leads to serious concerns for the risk of antimicrobial resistance.”

Marie-Paule Kieny

According to WHO, 11% of patients in low- and middle-income countries undergoing surgery and, in Africa, up to 20% of women who have a cesarean delivery develop infections. Each year in the United States, surgical site infections (SSIs) result in an additional 400,000 hospital days at a cost of $900 million. To address the global burden of SSIs, a panel of 20 experts developed 29 recommendations — recently published in the Lancet Infectious Diseases — that are based on the most recent data demonstrating effective ways to prevent the infections.

“No one should get sick while seeking or receiving care,” Marie-Paule Kieny, MD, assistant director-general of health systems and innovation for WHO, said in a press release. “Preventing surgical infections has never been more important but it is complex and requires a range of preventive measures. These guidelines are an invaluable tool for protecting patients.”

For preoperative measures, the guideline panel recommends against removing hair from the surgical area, or to at least use a clipper and not a razor. It also recommends against using antimicrobial sealants after skin preparation, as a meta-analysis showed the sealants did not benefit or harm surgical patients.

The preoperative guidelines do recommend:

ensuring patients bathe or shower prior to surgery with plain or antimicrobial soap;
administering preoperative oral antibiotics combined with mechanical bowel preparation in adult patients undergoing elective colorectal surgery;
administering SAP typically within 120 minutes before incision;
using antimicrobial soap and water or a suitable alcohol-based hand rub before donning gloves;
using alcohol-based antiseptic solutions based on chlorhexidine gluconate for skin preparation;
administering perioperative intranasal applications of mupirocin 2% ointment with or without a combination of chlorhexidine gluconate body wash in known Staphylococcus aureus nasal carriers, particularly among those undergoing cardiothoracic and orthopedic surgery,
using immunosuppressive medication; and
to consider giving oral or enteral multiple nutrient-enhanced nutritional formulas to underweight patients who are more susceptible to postoperative infections.

For intraoperative and postoperative measures, the panel does not recommend prolonging SAP after surgery; to continue perioperative antibiotic prophylaxis in the presence of a wound drain; to use advanced wound dressing over standard dressing; or to use laminar airflow ventilation systems over a conventional ventilation system.

The intraoperative and postoperative guidelines do recommend using:

triclosan-coated sutures;
sterile, disposable non-woven or sterile, reusable woven drapes and gowns;
irrigation with an aqueous povidone-iodine solution before closure;
warming devices to prevent unintended hypothermia;
prophylactic negative-pressure wound therapy on primarily closed incisions in high-risk wounds;
wound-protector devices during clean-contaminated, contaminated and dirty abdominal surgical procedures;
goal-directed fluid therapy intraoperatively;
an 80% fraction of inspired oxygen intraoperatively and for 2 to 6 hours post-operation in adult patients undergoing general anesthesia with endotracheal intubation; and
protocols for intensive perioperative blood glucose control for diabetic and non-diabetic adults.

“Sooner or later many of us will need surgery, but none of us wants to pick up an infection on the operating table,” Ed Kelley, MD, director of WHO’s department of service delivery and safety, said in the release. “By applying these new guidelines, surgical teams can reduce harm, improve quality of life and do their bit to stop the spread of antibiotic resistance. We also recommend that patients preparing for surgery ask their surgeon whether they are following WHO’s advice.” – by Stephanie Viguers

References:

Allegranzi B, et al. Lancet Infec Dis. 2016;doi:10.1016/S1473-3099(16)30398-X.

Allegranzi B, et al. Lancet Infec Dis. 2016;doi:10.1016/S1473-3099(16)30402-9.

Disclosures: Allegranzi reports no relevant financial disclosures. Please see the full study for a list of all other researchers’ relevant financial disclosures. Infectious Disease News was unable to confirm Kelley and Kieny's relevant financial disclosures.