Wound Infection Guidelines

Updated: Nov 26, 2019
  • Author: Hemant Singhal, MD, MBBS, MBA, FRCS, FRCS(Edin), FRCSC; Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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Guidelines

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 (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.
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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, [23]  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).
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WHO Guidelines on Surgical-Site Infection

In 2016, the World Health Organization (WHO) published the following guidelines regarding SSI [22] :

  • It is good clinical practice for patients to bathe or shower prior to surgery. Either plain soap or an antimicrobial soap may be used for this purpose.
  • Patients undergoing cardiothoracic and orthopedic surgery with known nasal carriage of S. aureus should receive perioperative intranasal applications of mupirocin 2% ointment with or without a combination of chlorhexidine gluconate (CHG) body wash.
  • Surgical antibiotic prophylaxis (SAP) should be administered prior to the surgical incision when indicated (depending on the type of operation). The panel recommends the administration of SAP within 120 min before incision, while considering the half-life of the antibiotic.
  • Preoperative oral antibiotics should be combined with mechanical bowel preparation to reduce the risk of SSI in adult patients undergoing elective colorectal surgery. 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.
  • In patients undergoing any surgical procedure, hair should either not be removed or, if absolutely necessary, should be removed only with a clipper. Shaving is strongly discouraged at all times, whether preoperatively or in the OR.
  • Alcohol-based antiseptic solutions are recommended based on CHG for surgical-site skin preparation in patients undergoing surgical procedures.
  • Antimicrobial sealants should not be used after surgical-site skin preparation for the purpose of reducing SSI.
  • 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.
  • Consider 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.
  • Do not discontinue immunosuppressive medication prior to surgery for the purpose of preventing SSI.
  • Adult patients undergoing general anesthesia with endotracheal intubation for surgical procedures should receive an 80% fraction of inspired oxygen intraoperatively and, if feasible, in the immediate postoperative period for 2-6 hours to reduce the risk of SSI.
  • Use triclosan-coated sutures for the purpose of reducing the risk of SSI, independent of the type of surgery.
  • Preoperative antibiotic prophylaxis should not be continued in the presence of a wound drain for the purpose of preventing SSI.
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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)
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