Global guidelines for the prevention of surgical site infection-WHO 2018

来自WHO 2018年发表的Global guidelines for the prevention of surgical site infection

Preoperative measures

Topic	Research questions	Recommendations	Strength	Quality of evidence
Preoperative bathing	1. Is preoperative bathing using an antimicrobial soap more effective in reducing the incidence of SSI in surgical patients compared to bathing with plain soap? 2. Is preoperative bathing with CHG-impregnated cloths more effective in reducing the incidence of SSI in surgical patients compared to bathing with antimicrobial soap?	It is good clinical practice for patients to bathe or shower prior to surgery. The panel suggests that either plain soap or an antimicrobial soap may be used for this purpose. The panel decided not to formulate a recommendation on the use of CHG- impregnated cloths for the purpose of reducing SSI due to the very low quality of evidence.	Conditional	Moderate
Decolonization with mupirocin ointment with or without CHG body wash for the prevention of Staphylococcus aureus infection in nasal carriers	Is mupirocin nasal ointment in combination with or without CHG body wash effective in reducing the number of S. aureus infections in nasal carriers undergoing surgery?	The panel recommends that patients undergoing cardiothoracic and orthopaedic surgery with known nasal carriage of S. aureus should receive perioperative intranasal applications of mupirocin 2% ointment with or without a combination of CHG body wash. The panel suggests considering to treat also patients with known nasal carriage of S. aureus undergoing other types of surgery with perioperative intranasal applications of mupirocin 2% ointment with or without a combination of CHG body wash.	Strong Conditional	Moderate Moderate
Screening of ESBL colonization and the impact on antibiotic prophylaxis	1. Should SAP be modified in high (>10%) ESBL prevalence areas? 2. Should SAP be modified in patients who are colonized with or a carrier of ESBL? 3. Should patients be screened for ESBL prior to surgery?	The panel decided not to formulate a recommendation due to the lack of evidence.
Optimal timing for preoperative SAP	How does the timing of SAP administration impact on the risk of SSI and what is the precise optimal timing?	The panel recommends that 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 minutes before incision, while considering the half-life of the antibiotic.	Strong Strong	Low Moderate
Mechanical bowel preparation and the use of oral antibiotics	Is mechanical bowel preparation combined with or without oral antibiotics effective for the prevention of SSI in colorectal surgery?	The panel suggests that preoperative oral antibiotics combined with mechanical bowel preparation should be used to reduce the risk of SSI in adult patients undergoing elective colorectal surgery. The panel recommends that 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.	ConditionalStrong	Moderate Moderate
Hair removal	1. Does hair removal affect the incidence of SSI? 2. What method and timing of hair removal is associated with the reduction of SSI?	The panel recommends that 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.	Strong	Moderate
Surgical site preparation	Should alcohol-based antiseptic solutions or aqueous solutions be used for skin preparation in surgical patients and, more specifically, should CHG or PVP-I solutions be used?	The panel recommends alcohol-based antiseptic solutions based on CHG for surgical site skin preparation in patients undergoing surgical procedures.	Strong	Low to moderate
Antimicrobialsealants skin	Should antimicrobial sealants (in addition to standard surgical site skin preparation) be used in surgical patients for the prevention of SSI compared to standard surgical site skin preparation only?	The panel suggests that antimicrobial sealants should not be used after surgical site skin preparation for the purpose of reducing SSI.	Conditional	Very Low
Surgical hand preparation	1. What is the most effective type of product for surgical hand preparation to prevent SSI? 2. What is the most effective technique and ideal duration for surgical hand preparation?	The panel recommends that 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.	Strong	Moderate

Preoperative and/or intraoperative measures

Topic	Research questions	Recommendations	Strength	Quality of evidence
Enhanced nutritional support	In surgical patients, should enhanced nutritional support be used for the prevention of SSI?	The panel suggests considering 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.	Conditional	Very Low
Perioperative discontinuation of immunosuppressive agents	Should immunosuppressive agents be discontinued perioperatively and does this affect the incidence of SSI?	The panel suggests not to discontinue immunosuppressive medication prior to surgery for the purpose of preventing SSI.	Conditional	Very Low
Perioperative oxygenation	How safe and effective is the perioperative use of an increased fraction of inspired oxygen in reducing the risk of SSI?	The panel suggests that adult patients undergoing general anaesthesia with tracheal 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.	Conditional	Moderate
Maintaining normal body temperature (normothermia)	Should systemic body warming vs. no warming be used for the prevention of SSI in surgical patients?	The panel suggests the use of warming devices in the operating room and during the surgical procedure for patient body warming with the purpose of reducing SSI.	Conditional	Moderate
Use of protocols for intensive perioperative blood glucose control	1. Do protocols aiming to maintain optimal perioperative blood glucose levels reduce the risk of SSI? 2. What are the optimal perioperative glucose target levels in diabetic and non-diabetic patients?	The panel suggests the use of protocols for intensive perioperative blood glucose control for both diabetic and non-diabetic adult patients undergoing surgical procedures to reduce the risk of SSI. The panel decided not to formulate a recommendation on this topic due to the lack of evidence to answer question 2.	Conditional	Low
Maintenance of adequate circulating volume control/ normovolemia	Does the use of specific fluid management strategies during surgery affect the incidence of SSI?	The panel suggests the use of goal-directed fluid therapy intraoperatively to reduce the risk of SSI.	Conditional	Low
Drapesgowns and	1. Is there a difference in SSI rates depending on the use of disposable non-woven drapes and gowns or reusable woven drapes and gowns? 1.1. Is there a difference in SSI rates depending on the use of disposable non-woven or reusable woven drapes? 1.2. Is there a difference in SSI rates depending on the use of disposable non-woven or reusable woven gowns? 2. Does the use of disposable, adhesive, incise drapes reduce the risk of SSI?	The panel suggests that either sterile, disposable non-woven or sterile, reusable woven drapes and gowns can be used during surgical operations for the purpose of preventing SSI. No specific evidence was retrieved to answer to questions 1.1 and 1.2. The panel suggests not to use plastic adhesive incise drapes with or without antimicrobial properties for the purpose of preventing SSI.	Conditional Conditional	Moderate to very low Lowveryto low
Wound protector devices	Does the use of wound protector devices reduce the rate of SSI in open abdominal surgery?	The panel suggests considering the use of wound protector devices in clean-contaminated, contaminated and dirty abdominal surgical procedures for the purpose of reducing the rate of SSI.	Conditional	Very low
Incisional wound irrigation	Does intraoperative wound irrigation reduce the risk of SSI?	The panel considered that there is insufficient evidence to recommend for or against saline irrigation of incisional wounds before closure for the purpose of preventing SSI. The panel suggests considering the use of irrigation of the incisional wound with an aqueous PVP-I solution before closure for the purpose of preventing SSI, particularly in clean and clean-contaminated wounds. The panel suggests that antibiotic incisional wound irrigation should not be used for the purpose of preventing SSI.	NA ConditionalConditional	NA Low Low
Prophylactic negative pressure wound therapy	Does prophylactic negative pressure wound therapy reduce the rate of SSI compared to the use of conventional dressings?	The panel suggests the use of prophylactic negative pressure wound therapy in adult patients on primarily closed surgical incisions in high-risk wounds for the purpose of the prevention of SSI, while taking resources into account.	Conditional	Low
Use of surgical gloves	1. When is double- gloving recommended? 2. What are the criteria for changing gloves during an operation? 3. What type of gloves should be used?	The panel decided not to formulate a recommendation due to the lack of evidence to assess whether double- gloving or a change of gloves during the operation or the use of specific types of gloves are more effective in reducing the risk of SSI.
Changing of surgical instruments	At the time of wound closure, is there a difference in SSI when instruments are changed for fascial, subcutaneous and skin closure using a new set of sterile instruments?	The panel decided not to formulate a recommendation on this topic due to the lack of evidence.
Antimicrobial -coated sutures	Are antimicrobial-coated sutures effective to prevent SSI? If yes, when and how should they be used?	The panel suggests the use of triclosan-coated sutures for the purpose of reducing the risk of SSI, independent of the type of surgery.	Conditional	Moderate
Laminar flow ventilation systems in the context of OR ventilation	1. Is the use of laminar air flow in the OR associated with the reduction of overall or deep SSI? 2. Does the use of fans or cooling devices increase SSIs? 3. Is natural ventilation an acceptable alternative to mechanical ventilation?	The panel suggests that laminar airflow ventilation systems should not be used to reduce the risk of SSI for patients undergoing total arthroplasty surgery. The panel decided not to formulate a recommendation on these topics due to the lack of evidence to answer questions 2 and 3.	ConditionalNA	Low to very low NA

Postoperative measures

Topic	Research questions	Recommendations	Strength	Quality of evidence
SAP prolongation	Does continued postoperative SAP reduce the risk of SSI compared with preoperative and (if necessary) intraoperative prophylaxis only?	The panel recommends against the prolongation of SAP after completion of the operation for the purpose of preventing SSI.	Strong	Moderate
Advanced dressings	In surgical patients, should advanced dressings vs. standard sterile wound dressings be used for the prevention of SSI?	The panel suggests not usingany type of advanced dressing over a standard dressing on primarily closed surgical wounds for the purpose of preventing SSI.	Conditional	Low
Antimicrobial prophylaxis in the presence of a drain and optimal timing for wound drain removal	1. In the presence of drains, does prolonged antibiotic prophylaxis prevent SSI? 2. When using drains, how long should they be kept in place to minimize SSI as a complication?	The panel suggests that preoperative antibiotic prophylaxis should not be continued in the presence of a wound drain for the purpose of preventing SSI. The panel suggests removingthe wound drain when clinically indicated. No evidence was found to allow making a recommendation on the optimal timing of wound drain removal for the purpose of preventing SSI.	ConditionalConditional	Low Verylow

缩写说明

缩写	全称
ABHR	alcohol-based handrub
AMR	antimicrobial resistance
ASHP	American Society of Health-System Pharmacists
CDC	Centers for Disease Control and Prevention
CHG	chlorhexidine gluconate
CI	confidence interval
ECDC	European Centre for Disease Prevention and Control
ESBL	extended spectrum beta-lactamase
FiO2	fraction of inspired oxygen
GDFT	goal-directed fluid therapy
GDG	Guidelines Development Group
GRADE	Grading of Recommentations Assessment, Development and Evaluation
HAI	health care-associated infection
IDSA	Infectious Diseases Society of America
IPC	infection prevention and control
LMICs	low- and middle-income countries
MBP	mechanical bowel preparation
MRSA	methicillin-resistant Staphylococcus aureus
MSSA	methicillin-susceptible Staphylococcus aureus
MTX	methotrexate
NHSN	National Healthcare Safety Network
NICE	National Institute for Health and Care Excellence
NNIS	National Nosocomial Infections Surveillance System
OR	odds ratio
PAHO	Pan American Health Organization
PHMB	polyhexamethylene biguanide
PICO	Population, Intervention, Comparison, Outcomes
pNPWT	prophylactic negative pressure wound therapy
PVP-I	povidone-iodine
RCT	randomized clinical trial
SAP	surgical antibiotic prophylaxis
SHEA	Society of Healthcare Epidemiology of America
SIGN	Scottish Intercollegiate Guidelines Network
SREG	Systematic Reviews Expert Group
SSI	surgical site infection/s
THA	total hip arthroplasty
TKA	total knee arthroplasty
TNF	tumour necrosis factor
UK	United Kingdom
USA	United States of America
v/v	volume/volume
WHO	World Health Organization
WFSA	World Federation of Societies of Anesthesiologists
WP	wound protectors