APSIC Guidelines for Prevention of Surgical-Site Infection

In 2019, the Asia Pacific Society of Infection Control (APSIC) issued the following guidelines for the prevention of surgical-site infection (SSI)^[24]:

Perform surveillance of SSIs using accepted international methodology.
It is necessary for patients who will undergo surgery to have at least one preoperative bath with soap (antimicrobial or nonantimicrobial).
A combination of mechanical bowel preparation and oral antibiotic preparation is recommended for all elective colorectal surgery in adults.
Hair removal should be avoided unless hair interferes with the operative procedure. If hair removal is necessary, a razor should be avoided, and an electric clipper should be used. No recommendation is made regarding the timing of hair removal by clipper.
Hospitals should evaluate their SSI rate, Staphylococcus aureus and methicillin-resistant S aureus (MRSA) rates, and mupirocin resistance rate, if available, to determine whether implementation of a screening program is appropriate.
Patients undergoing cardiothoracic and orthopedic surgery with known nasal carriage of S aureus should receive perioperative intranasal application of mupirocin 2% ointment, with or without a combination of chlorhexidine body wash.
Surgical hand preparation is to be performed either by scrubbing with a suitable antiseptic soap and water or by using a suitable alcohol-based hand rub (ABHR) before sterile gown and gloves are donned. ABHRs used in surgical hand preparation should comply with EN 12791 or ASTM E-1115 standards.
Where the quality of water used is not assured, use of an ABHR is recommended.
Alcohol-based skin antiseptic preparations should be used, unless contraindicated.
Administration of prophylactic antimicrobials should be performed only when indicated. It should take place within 1 hour before incision for all antimicrobials except vancomycin and fluoroquinolones, for which it should take place within 2 hours before incision. Redosing should be considered to maintain adequate tissue levels on the basis of on agent half-life. A single dose of a prophylactic antimicrobial is adequate for most surgical procedures.
Underweight patients undergoing major surgical procedures, especially oncologic and cardiovascular operations, may benefit from the administration of oral or enteral multiple nutrient-enhanced nutritional formulas for the purpose of preventing SSI.
Preoperative hemoglobin A1c levels should be below 8%.
Maintain perioperative normothermia by using active warming devices.
Hemodynamic goal-directed therapy is recommended to reduce SSI.
There is insufficient evidence to recommend for or against saline irrigation of incisional wounds before closure for the purpose of preventing SSI. Avoid using antimicrobial agents to irrigate incisional wounds before closure to reduce the risk of SSI.
Where there are high SSI rates in clean surgical procedures in spite of basic preventive measures, individual centers may consider the use of antimicrobial-impregnated sutures.
When using adhesive incise drapes for surgery, do not use non-iodophor-impregnated drapes; they may increase the risk of SSI. In orthopedic and cardiac surgical procedures where adhesive incise drapes are used, consider using an iodophor-impregnated incise drape, unless the patient has an iodine allergy or other contraindication.
Careful evaluation of wound protectors must be done before the use of wound protectors is introduced as a routine measure to reduce SSI.
Do not apply vancomycin powder into the surgical site for prevention of SSI.
Installation of laminar airflow is not required in new or renovated operating rooms (ORs) to prevent SSI.
Primary vacuum dressings or negative-pressure wound therapy (NPWT; ie, for clean-contaminated and contaminated surgical procedures) and silver-based dressings have mixed results; individualized decisions on their use are suggested. Routine use for prevention of SSI is not recommended.

WHO Guidelines on Surgical-Site Infection

In 2018, the World Health Organization (WHO) published the second edition of its guidelines regarding SSI,^[23]which included the following strong recommendations:

Patients with known nasal carriage of S aureus should receive intranasal applications of mupirocin 2% ointment, with or without a combination of chlorhexadine gluconate (CHG) body wash.
Mechanical bowel preparation alone (without oral antibiotics) should not be used in adult patients undergoing elective colorectal surgery.
In patients undergoing any surgical procedure, hair either should not be removed or, if removal is absolutely necessary, should be removed only with a clipper. Shaving is strongly discouraged at all times, whether preoperatively or in the OR.
Surgical antibiotic prophylaxis (SAP), when indicated, should be administered within 120 minutes before incision, with consideration given to the half-life of the antibiotic.
Surgical hand preparation should be performed either by scrubbing with a suitable antimicrobial soap and water or by using a suitable alcohol-based hand rub before donning sterile gloves.
Alcohol-based antiseptic solutions based on CHG should be used for surgical-site skin preparation in patients undergoing surgical procedures.
Adult patients undergoing general anesthesia with endotracheal intubation for surgical procedures should receive 80% fraction of inspired oxygen intraoperatively and, if feasible, immediately after the procedure for 2-6 hours.
SAP should not be prolonged after completion of the operation.

CDC Guidelines for Prevention of Surgical-Site Infection

In 2017, the Centers for Disease Control and Prevention (CDC) published an updated guideline for the prevention of SSIs,^[22] which included the following recommendations:

Administer preoperative antimicrobial agents only when indicated by published clinical practice guidelines, and time administration so that a bactericidal concentration is established in serum and tissues when the incision is made (strong recommendation; accepted practice).
Administer appropriate parenteral prophylactic antimicrobial agents before skin incision in all cesarean section procedures (strong recommendation; high-quality evidence).
In clean and clean-contaminated procedures, do not administer additional prophylactic antimicrobial agent doses after the surgical incision is closed in the OR, even in the presence of a drain (strong recommendation; high-quality evidence).
Do not apply antimicrobial agents (ie, ointments, solutions, or powders) to the surgical incision with the aim of preventing SSI (strong recommendation; low-quality evidence).
Application of autologous platelet-rich plasma is not necessary for the prevention of SSI (weak recommendation; moderate-quality evidence suggesting a trade-off between clinical benefits and harms).
Consider the use of triclosan-coated sutures for the prevention of SSI (weak recommendation; moderate-quality evidence).
Implement perioperative glycemic control, and use blood glucose target levels lower than 200 mg/dL in patients with and without diabetes (strong recommendation; high- to moderate-quality evidence).
Maintain perioperative normothermia (strong recommendation; high- to moderate-quality evidence).
For patients with normal pulmonary function undergoing general anesthesia with endotracheal intubation, employ an increased fraction of inspired oxygen (FiO ₂) during the surgical procedure and after extubation in the immediate postoperative period; to optimize tissue oxygen delivery, maintain perioperative normothermia and adequate volume replacement (strong recommendation; moderate-quality evidence).
Advise patients to shower or bathe the full body with either antimicrobial or nonantimicrobial soap or an antiseptic agent on at least the night before the day of the procedure (strong recommendation; accepted practice).
Perform intraoperative skin preparation with an alcohol-based antiseptic agent unless this is contraindicated (strong recommendation; high-quality evidence).
Application of a microbial sealant immediately after intraoperative skin preparation is not necessary for the prevention of SSI (weak recommendation; low-quality evidence).
The use of plastic adhesive drapes with or without antimicrobial properties is not necessary for the prevention of SSI. (weak recommendation; high- to moderate-quality evidence).
Consider intraoperative irrigation of deep or subcutaneous tissues with aqueous iodophor solution for the prevention of SSI; intraperitoneal lavage with aqueous iodophor solution is not necessary in contaminated or dirty abdominal procedures (weak recommendation; moderate-quality evidence).
Do not withhold transfusion of necessary blood products from surgical patients undergoing prosthetic joint arthroplasty as a means of preventing SSI (strong recommendation; accepted practice).
In clean or clean-contaminted prosthetic joint arthroplasties, do not administer additional antimicrobial prophylaxis doses after the surgical incision is closed in the OR, even in the presence of a drain (strong recommendation; high-quality evidence).

IDSA Guidelines on Surgical-Site Infection

In 2014, the Infectious Diseases Society of America (IDSA) issued the following practice guidelines for the management of SSIs^[21]:

Suture removal plus incision and drainage should be performed for SSIs (strong recommendation, low-quality evidence)
Adjunctive systemic antimicrobial therapy is not routinely indicated but, in conjunction with incision and drainage, may be beneficial for SSIs associated with a significant systemic response, such as erythema and induration extending more than 5 cm from the wound edge, temperature exceeding 38.5°C, heart rate higher than 110 beats/min, or white blood cell (WBC) count higher than 12,000/µL (weak recommendation, low-quality evidence)
A brief course of systemic antimicrobial therapy is indicated in patients with SSIs after clean operations on the trunk, head and neck, or extremities that also have systemic signs of infection (strong recommendation, low-quality evidence)
A first-generation cephalosporin or an antistaphylococcal penicillin for methicillin-sensitive S aureus (MSSA)—or vancomycin, linezolid, daptomycin, telavancin, or ceftaroline where risk factors for methicillin-resistant S aureus (MRSA) are high (nasal colonization, prior MRSA infection, recent hospitalization, or recent antibiotics)—is recommended (strong recommendation, low-quality evidence)
Agents active against gram-negative bacteria and anaerobes, such as a cephalosporin or fluoroquinolone in combination with metronidazole, are recommended for infections after operations on the axilla, gastrointestinal tract, perineum, or female genital tract (strong recommendation, low-quality evidence)

Medication

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Media Gallery

Wound infection due to disturbed coagulopathy. This patient has a pacemaker (visible below right clavicular space) and had previous cardiac surgery (median sternotomy wound visible) for a rheumatic mitral valve disorder, which was replaced. The patient was taking anticoagulants preoperatively. Despite converting to low-molecular weight subcutaneous heparin treatment and establishing normal coagulation studies, she developed a postoperative hematoma with subsequent wound infection. She had the hematoma evacuated and was administered antibiotic treatment as guided by microbiological results, and the wound was left to heal by secondary intention.
Abscess secondary to a subclavian line.
Definitions of surgical site infection (SSI).
Factors that affect surgical wound healing.
Large ulceration in a tattoo. A 33-year-old man presented with a superficial ulceration about 4 weeks after a red tattoo on his forearm. Microbial swabs remained negative. His medical history was uneventful and he was in good general health. No reason for this uncommon reaction could be identified. Image courtesy of the National Institutes of Health.

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Table 1. Pathogens Commonly Associated with Wound Infections and Frequency of Occurrence ^[8]

Pathogen	Frequency (%)
Staphylococcus aureus	20
Coagulase-negative staphylococci	14
Enterococci	12
Escherichia coli	8
Pseudomonas aeruginosa	8
Enterobacter species	7
Proteus mirabilis	3
Klebsiella pneumoniae	3
Other streptococci	3
Candida albicans	3
Group D streptococci	2
Other gram-positive aerobes	2
Bacteroides fragilis	2

Table 2: Surgical Wound Classification and Subsequent Risk of Infection (If No Antibiotics Used) ^{[8, 10]}

Classification	Description	Infective Risk (%)
Clean (Class I)	Uninfected operative wound No acute inflammation Closed primarily Respiratory, gastrointestinal, biliary, and urinary tracts not entered No break in aseptic technique Closed drainage used if necessary	< 2
Clean-contaminated (Class II)	Elective entry into respiratory, biliary, gastrointestinal, urinary tracts and with minimal spillage No evidence of infection or major break in aseptic technique Example: appendectomy	< 10
Contaminated (Class III)	Nonpurulent inflammation present Gross spillage from gastrointestinal tract Penetrating traumatic wounds < 4 hours Major break in aseptic technique	About 20
Dirty-infected (Class IV)	Purulent inflammation present Preoperative perforation of viscera Penetrating traumatic wounds >4 hours	About 40

Table 3. Recommendations for Prophylactic Antibiotics as Indicated by Probable Infective Microorganism Involved ^{[8, 30]}

Operation	Expected Pathogens	Recommended Antibiotic
Orthopedic surgery (including prosthesis insertion), cardiac surgery, neurosurgery, breast surgery, noncardiac thoracic procedures	S aureus, coagulase-negative staphylococci	Cefazolin 1-2 g
Appendectomy, biliary procedures	Gram-negative bacilli and anaerobes	Cefazolin 1-2 g
Colorectal surgery	Gram-negative bacilli and anaerobes	Cefotetan 1-2 g or cefoxitin 1-2 g plus oral neomycin 1 g and oral erythromycin 1 g (start 19 h preoperatively for 3 doses)
Gastroduodenal surgery	Gram-negative bacilli and streptococci	Cefazolin 1-2 g
Vascular surgery	S aureus, Staphylococcusepidermidis, gram-negative bacilli	Cefazolin 1-2 g
Head and neck surgery	S aureus, streptococci, anaerobes and streptococci present in an oropharyngeal approach	Cefazolin 1-2 g
Obstetric and gynecological procedures	Gram-negative bacilli, enterococci, anaerobes, group B streptococci	Cefazolin 1-2 g
Urology procedures	Gram-negative bacilli	Cefazolin 1-2 g

Table 4. Predictive Percentage of SSI Occurrence by Wound Type and Risk Index* ^[31]

At Risk Index	Predictive Percentage of SSI
0	1.5
1	2.9
2	6.8
3	13.0
*Hospital Infection Control Practices Advisory Committee (HICPAC) recommendations (partial) for the prevention of SSIs, April 1999 (non–drug based)

Table 5. American Society of Anesthesiologists (ASA) Classification of Physical Status ^[32]

ASA Score	Characteristics
1	Normal healthy patient
2	Patient with mild systemic disease
3	Patient with a severe systemic disease that limits activity but is not incapacitating
4	Patient with an incapacitating systemic disease that is a constant threat to life
5	Moribund patient not expected to survive 24 hours with or without operation

Table 6. Data Support Recommendations

Category	Description
Category IA	Well designed, experimental, strong; recommended (category I*) clinical or epidemiological best practice; should be studies; adapted by all practices
Category IB	Some experimental, fairly strong; recommended (category II*) clinical or epidemiological best practice; should be studies and theoretical grounds; adapted by all practices
Category II	Fewer scientific supporting data; limited to specific nosocomial (category III*) problems
No recommendation	Insufficient scientific personnel judgment for use (category III*) supporting data
*Previous nomenclature of 1992 CDC guidelines