WHO guidelines for prevention of surgical site infections: pre-operative measures
Surgical site infections (SSIs) are responsible for a large proportion of healthcare-associated infections, being the second most common cause of these infections in Europe and the USA. Prevention programs for SSIs are complex and multi-factorial, and require key strategies to be implemented in pre-, intra- and post-operative periods. As such, the WHO convened an expert/consensus group to evaluate evidence-based prevention strategies focussed on pre-operative measures (Lancet Infect Dis 2016; 16: e276–87). Each recommendation is graded according to strength (strong or conditional) and quality.
Pre-operative measures for SSI prevention are summarised as thirteen recommendations, including:
(i) Immunosuppressive medication should not be discontinued before surgery,
(ii) Consider the administration of oral or enteral multiple nutrient-enhanced nutritional formulas in underweight patients who undergo major surgical operations,
(iii) Patients should bathe or shower before surgery; either a plain soap or an antimicrobial soap may be used for this purpose,
(iv) Patients undergoing cardiothoracic or orthopaedic surgery with known nasal carriage of S. aureus should receive perioperative intranasal applications of mupirocin 2% ointment with or without a combination of chlorhexidine (CHG) body wash,
(v) Perioperative intranasal applications of mupirocin 2% ointment with or without a combination of CHG bodywash are suggested to be used also in patients undergoing other types of surgery,
(vi) Preoperative oral antibiotics combined with mechanical bowel preparation are suggested for use in adult patients undergoing elective colorectal surgery,
(vii) Mechanical bowel preparation alone (without administration of oral antibiotics) should not be used in adult patients undergoing elective colorectal surgery,
(viii) 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,
(ix) Administration of surgical antibiotic prophylaxis (SAP) should be before the surgical incision when indicated,
(x) SAP should be administered within 120 min before incision, while considering the half-life of the antibiotic,
(xi) Surgical hand preparation should be performed either by scrubbing with a suitable antimicrobial soap and water or using a suitable alcohol-based hand rub before donning sterile gloves,
(xii) Alcohol-based antiseptic solutions based on CHG for surgical site skin preparation should be used in patients undergoing surgical procedures, and
(xiii) Antimicrobial sealants should not be used after surgical site skin preparation for the purpose of reducing SSI.
These recommendations are a valuable resource for hospital infection programs in developed countries. However, given the quality of evidence, conditional recommendations must be evaluated locally by stakeholders, and in the context of the patient and surgical factors most frequently encountered within an individual healthcare facility.