- Don't discontinue immunosuppressive medications before surgery. It can induce a flare of disease activity and interruption of therapy may induce anti-drug antibodies. There is low quality evidence that there may be a reduction in SSIs with anti-TNF drug discontinuation only.
- Give multiple nutrient-enhanced nutritional formulas to underweight patients undergoing major surgery.
- Patients should bathe or shower before surgery with either plain or antimicrobial soap. Either type of soap can be used based on the evidence.
- Patients with known nasal carriage of Staphylococcus Aureus should recieve intranasal applications of mupirocin 2% ointment. The ointment should be applied nasally twice daily for five days. S.aureus carriage is a risk factor for SSIs. There is evidence for effectiveness of this for only cardiothoracic and orthopedic procedures but the panels suggests for all types of surgery. The ointment is only for KNOWN carriers to prevent unnecessary treatment and resistance spread.
- Adult patients undergoing colorectal procedures should have preoperative antibiotics combined with mechanical bowel preparation (MBP) prior to surgery. The use of MBP reduces the intraluminal faecal mass and therefore bacterial load, alongside further bacterial load reduction with antibiotics. The potential harms of MBP should be considered; patient discomfort, electrolyte abnormalities, dehydration, acute phosphate nephropathy. Most common antibiotic regime in the evidence was aminoglycosides combined with anaerobic coverage (metronidazole).
- Hair removal should be with clippers NOT with shaving. This is because microscopic trauma to the skin can increase SSI risk.
- Surgical antibiotic prophylaxis should be done within 120 minutes before skin incision. The evidence showed increased SSIs if the antibiotics were given after skin incision or before 120minutes (note the evidence was of low quality though). Antibiotics with a short half life such as cefazolin or cefoxitin should be given closer to the skin incision time e.g. less than 60min before.
- Surgical hand preparation is vitally important! scrubbing should be done with either antiseptic soap or an alcohol based hand rub (ABHR). There was no difference between povidone-iodine or chlorohexidine. ABHR reduced the number of colony forming units more than antiseptic soap.
- Alcohol based antiseptic solution based on chlorhexidine-gluconate should be used for skin preparation. Alcohol solutions were shown to be more effective than aqueous solutions. Although alcohol based solutions should not be used on neonates and caution should be exercised to prevent contact with eyes, mucosa or accumulation for its flammable nature. Chlorhexidine should absolutely be kept away from the brain, meninges, eyes and middle ear.
- Antimicrobial sealants should not be used. There was no benefit for their use in the literature in preventing SSIs.
- Adult patients undergoing general anaesthesia with endotracheal intubation should receive an 80% fraction of inspired oxygen intraoperatively and if feasible in the immediate postoperative period for 2-6 hours. Infected tissue tends to have a lower oxygen tension than tissue that is non-infected, perhaps due to enhanced oxidative killing by neutrophils. In the postoperative period this benefit was observed with use of a high-flux mask and when normovolemia and normothermia was maintained.
- Normothermia should be maintained with the use of warming devices during the procedure. There are many adverse effects from a hypothermic state (<36degrees); increased cardiac complications, impaired coagulation, impaired wound healing, decreased drug metabolism, decreased immune metabolism and increased SSI incidence.
- Intensive perioperative glucose control. Using an intensive protocol reduced the SSIs although neither an optimal target glucose concentration or timing of control coudl be defined by thepanel. Blood glucose must be closely monitored and hypoglycemia avoided at all costs.
- Sterile disposable or reusable drapes and gowns should be used (Duh!). Although interesting the panel says plastic adhesive incise drapes should be avoided something we use regularly in my unit hmm (apparently they don't effect SSI incidence at all, yeah maybe they dont effect skin edge infection rates but im sure they can help prevent graft infection rates if you are using non native prothesis or grafts, a question for another time, let me find out).
- Wound protector device use should be considered. These devices, small clips that cover the wound edge have been associated with significantly reduced risk of SSI.
- You should irrigate the incisional wound with an aquaous povidone-iodine solution before closure. It removes cellular debris and dliutes possible contamination, results were heterogenous, favouring wound irrigation slightly.
- High risk wounds should be treated with prophylactic negative-pressure wound therapy (pNPWT). PNPWT was shown to significantly reduced SSIs compared to conventional dressings in abdominal and cardiac high risk insicions. A high risk incision is one with poor tissue perfusion, decreased blood flow, hematoma or obvious dead space.
- Antibiotic coated/triclosan coated sutures should be used. Evidence showed that ticlosan coated sutures had a significant effect in reducing SSIs, although there was a statment over possible study limitations due to industry sponsorship.
- Laminar airflow ventilation has no benefit compared to conventional operating room ventilation and shouldn't be used to reduce SSIs.
- Antibiotic prophylaxis should not be prolonged for presence of a wound drain and drains should be removed when clinically indicated. drains can adversly effect the outcomes by affecting anastomotic healing and propagating infections.
- Advanced dressings should not be used over standard surgical dressings for purpose of SSI prevention. There was no evidence that advanced dressings (e.g. silver impregnated) had any benefit over standard gauze dressings.
- Surgical antibiotic prophylaxis (SAP) should not be prolonged after the operation. Most guidelines recommend a maximum SAP duration of 24 hours, infact a single preoperative dose might be non inferior. Surgeons are regularly documented prolonging SAP, this is unnesscary and risks increasing antibiotic reisstance rates. Author does note that prolonging SAP may have a benefit in cardiac and orthognathic surgery only.
The links to the papers where all this was taken from:
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