Preoperative Interventions for the Prevention of Surgical Site Infections: A Review of Guidelines

Yan Li; Melissa Severn

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Preoperative Interventions for the Prevention of Surgical Site Infections: A Review of Guidelines

CADTH Rapid Response Report: Summary with Critical Appraisal

Yan Li and Melissa Severn.

Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2020 Jun 18.

Context and Policy Issues

Defined as postoperative infections of an incision, organ, or space,¹ surgical site infections (SSIs) are the most common health care-related infections.² Occurring in up to 5% of all surgeries, SSIs affect approximately 26,000 to 65,000 Canadian patients annually.² Due to increased hospital stays and readmission rates, SSIs cost the health care system between $350,000 to $1 million each year.² To help reduce morbidity, extended hospitalization, and death, infection control measures have been implemented in surgical settings.²

Surgical infection control measures include staff precautions such as practicing hand hygiene and using barrier devices, and patient-specific perioperative infection control interventions that may include nasal decolonization for Staphylococcus aureus (S. aureus), preoperative washing, skin antisepsis, hair removal, glucose control, bowel preparation, and antibiotic prophylaxis.³ It has been shown that almost half of SSIs may be prevented by applying evidence-based strategies.⁴ SSI prevention measures can be bundled to promote staff and patient adherence, but there is a lack of consensus regarding the appropriate components of an infection control bundle.³

This report is an upgrade from a previous CADTH Reference List report published in 2020, and includes one of the research questions from that report.⁵ The aim of the current report is to summarize and critically appraise the relevant evidence-based guidelines identified in the previous report⁵ regarding preoperative interventions for the prevention of SSIs.

Research Question

What are the evidence-based guidelines regarding preoperative interventions for the prevention of surgical site infections?

Key Findings

Six evidence-based guidelines regarding the use of preoperative interventions for the prevention of surgical site infections were included in this report. Four included guidelines were of high quality, while two guidelines were of moderate quality due to unclear reporting of methodological details.

Of these guidelines, for the purpose of infection prevention, four recommend nasal decolonization with mupirocin, body washing with chlorhexidine gluconate, and bathing with antimicrobial or non-antimicrobial soap prior to surgery. Furthermore, four guidelines recommend the use of alcohol-based solutions for skin antiseptic preparation but recommend against hair removal unless absolutely required. Three guidelines recommend mechanical bowel preparation with oral antibiotics for elective colorectal surgery, while one guideline recommends against its use with no mention of specific indications or concurrent antibiotic use. Two guidelines made recommendations on perioperative blood glucose control with different target levels. Four guidelines made recommendations on the optimal time for administering antibiotic prophylaxis (i.e., at one or two hours before incision, or at the time of anesthesia). Overall, these recommendations ranged from conditional to strong and were based on evidence that ranged in quality from very low to high (when reported).

Methods

Literature Search Methods

The literature search that was conducted for a previous CADTH report⁵ was used for this report. A limited literature search was conducted by an information specialist on key resources including Medline via Ovid, the Cochrane Library, the University of York Centre for Reviews and Dissemination (CRD) databases, the websites of Canadian and major international health technology agencies, as well as a focused internet search. The search strategy was comprised of both controlled vocabulary, such as the National Library of Medicine’s MeSH (Medical Subject Headings), and keywords. The main search concepts in the previous CADTH report⁵ were surgical site infections in the preoperative setting. Methodological filters were applied to limit the retrieval to guidelines only. The search was also limited to English language documents published between January 1, 2015 and February 27, 2020.

Selection Criteria and Methods

One reviewer screened citations and selected studies. In the first level of screening, titles and abstracts were reviewed and potentially relevant articles were retrieved and assessed for inclusion. The final selection of full-text articles was based on the inclusion criteria presented in Table 1.

Table 1

Selection Criteria.

Exclusion Criteria

Articles were excluded if they did not meet the selection criteria outlined in Table 1, they were duplicate publications, or were published prior to 2015. Guidelines with unclear methodology were excluded.

Critical Appraisal of Individual Studies

The included guidelines were critically appraised by one reviewer using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument⁶ as a guide. Summary scores were not calculated for the included studies; rather, a review of the strengths and limitations of each included guideline were described narratively.

Summary of Evidence

Quantity of Research Available

A total of 354 citations were identified in the literature search. Following screening of titles and abstracts, 350 citations were excluded and 4 potentially relevant reports from the electronic search were retrieved for full-text review. Eight potentially relevant publications were retrieved from the grey literature search for full-text review. Of these potentially relevant articles, six publications were excluded for various reasons, and six evidence-based guidelines met the inclusion criteria and were included in this report. Appendix 1 presents the PRISMA⁷ flowchart of the study selection.

Additional publications of potential interest are provided in Appendix 5.

Summary of Study Characteristics

Six evidence-based guidelines were identified and included in this report.¹^,⁸^–¹² Detailed characteristics of the guidelines are available in Appendix 2.

Study Design

Six evidence-based guidelines were identified regarding preoperative interventions for the prevention of SSIs.¹^,⁸^–¹² Two of these guidelines were published in 2019 and were developed by the Asia Pacific Society of Infection Control (APSIC)¹¹ and the National Institute for Health and Care Excellence (NICE).⁹ Two guidelines were published in 2017 and were developed by the American College of Surgeons (ACS) & Surgical Infection Society¹² and the US Centers for Disease Control and Prevention (CDC).¹ The guidelines developed by the WHO⁸ and the Ministry of Health Malaysia¹⁰ were published in 2016 and 2015, respectively.

The CDC guidelines were informed by a SR which included systematic searches from 1998 through April 2014 for relevant randomized controlled trials (RCTs) and SRs.¹ The WHO guidelines were informed by a SR which included systematic searches between December 2013 and October 2015 for RCTs and non-randomized studies.⁸ The NICE guidelines were informed by systematic searches on March 15, 2018 and screened for RCTs and SRs of RCTs.⁹ The Ministry of Health Malaysia guidelines were informed by systematic searches from 2003 onwards and screened for SRs, RCTs, and non-randomized studies.¹⁰ The APSIC guidelines¹¹ were informed by computerized literature searches on PubMed and a review of other published guidelines (e.g., CDC, WHO), while the ACS guidelines¹² were informed by literature searches on PubMed.

The NICE,⁹ CDC,¹ and WHO⁸ guidelines used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to evaluate the quality of the evidence. The NICE guideline graded the quality of evidence from very low to high, and reflected the strength of recommendations in the wording (i.e., “offer/advise” was used for strong recommendations with clear evidence of benefit, while “consider” was used if the evidence was less certain).⁹ The CDC guideline graded the quality of evidence from C (i.e., required by state/federal regulation) to A (i.e., high to moderate-quality evidence), and classified the strength of recommendation from no recommendation to strong recommendation.¹ The WHO guideline graded the quality of evidence from very low to high, and classified the strength of recommendation as conditional or strong.⁸

The authors of the APSIC guideline assessed the quality of evidence as category III (i.e., evidence from opinions or expert committee reports) to category I (i.e., evidence from ≥ one RCT), and rated the strength of recommendation from E (i.e., good evidence to recommend against use) to A (i.e., good evidence to recommend use).¹¹ The guideline development group for the Ministry of Health Malaysia guideline used the US/Canadian Preventive Services Task Force guide to classify the quality of evidence from category III (i.e., evidence from opinions or expert committee reports) to category I (i.e., evidence from ≥ one RCT), and rated the strength of recommendation using the Scottish Intercollegiate Guidelines Network system from C (i.e., evidence from opinions or expert committee reports) to A (i.e., evidence from ≥ one meta-analysis, SR, or RCT).¹⁰ The authors of the ACS guideline did not report assessment of the quality of the evidence or grade the strength of the recommendations.¹²

The rating systems for quality of evidence and strength of recommendations, if available, are reported in Appendix 4. Decisions on the recommendations were reached through consensus in five guidelines,¹^,⁸^–¹⁰^,¹² while the methodology for formulating the recommendations was not reported in the APSIC guideline.¹¹

Country of Origin

The WHO guideline⁸ is meant to apply globally, while the ACS¹² and CDC¹ guidelines are meant to apply to the United States. The other three guidelines are meant to apply to the Asia Pacific region,¹¹ the United Kingdom,⁹ and Malaysia.¹⁰

Patient Population

The target population covered by the six guidelines was patients undergoing surgical procedures.¹^,⁸^–¹² The Ministry of Health Malaysia guideline specifically focused on patients undergoing oral and maxillofacial surgical procedures.¹⁰ The intended users of four guidelines are surgical staff who provide care for surgical patients.¹^,⁸^–¹² In two guidelines, the intended users were not explicitly stated, but they appear to be intended for surgical staff. ¹¹^,¹² The CDC,¹ WHO,⁸ and Ministry of Health Malaysia¹⁰ guidelines are also intended for professional societies and organizations, anesthesiologists and pharmacists, and dental practitioners and educators, respectively.

Interventions and Comparators

The six guidelines considered a variety of preoperative interventions that can be used to help prevent SSIs.¹^,⁸^–¹² These included preoperative body washing, mechanical bowel preparation, antibiotic prophylaxis, hair removal, skin antiseptic, glucose control, and nasal decolonization.

Outcomes

All six guidelines considered the incidence of SSIs.¹^,⁸^–¹² Three guidelines also considered SSI-related deaths,¹^,⁸^,⁹ and two guidelines¹^,⁹ considered duration of hospital stay, hospital readmission, antimicrobial resistance, and adverse events. Additionally, the NICE guideline considered postoperative antibiotic use, infection complications, and other nosocomial infections as outcomes.⁹

Summary of Critical Appraisal

Additional details regarding the AGREE II evaluation of the included guidelines are provided in Appendix 3.

The guideline development groups for all six guidelines were comprised of experts from multidisciplinary areas. All guidelines provided a clear description of their objectives, specified the target populations, and provided unambiguous and easily identifiable recommendations.¹^,⁸^–¹² The views of the funding sources did not appear to have influenced the guidelines’ contents.¹^,⁸^–¹² However, the views and preferences of the target population were not sought and the target users of the guidelines were not explicitly defined in two guidelines.¹¹^,¹²

With respect to rigour of guideline development, the APSIC¹¹ and the ACS¹² guideline provided brief details of their methodology without search timeframes. Additionally, the authors of these two guidelines conducted literature searches in one database (i.e., PubMed), which may have resulted in omission of relevant information. The methodology for formulating the recommendations was not reported in the APSIC guideline.¹¹ The authors of the ACS guideline did not assess the quality of the evidence or grade the strength of the recommendations.¹² In the NICE guideline, the supporting evidence used to inform the recommendations on preoperative bathing, hair removal, mechanical bowel preparation, and antibiotic prophylaxis was not updated since the original 2008 guideline publication.¹³ Furthermore, the quality of the aforementioned supporting evidence was not available online. The recommendations on preoperative washing, nasal decolonization, and skin antisepsis were updated in the current NICE guideline.⁹ All six guidelines were externally reviewed prior to publication.¹^,⁸^–¹² However, three guidelines did not explicitly describe procedures for guideline updates.¹⁰^–¹²

In terms of guideline applicability, all six guidelines presented monitoring criteria for their recommendations. The NICE⁹ CDC,¹ and WHO⁸ guideline described facilitators or barriers to their application and provided tools for putting recommendations into practice. Four guidelines did not consider the potential resource implications of applying the recommendations.¹^,¹⁰^–¹² Finally, the six guidelines were developed for use in the Asia Pacific region,¹¹ Malaysia,¹⁰ United Kingdom,⁹ United States,¹^,¹² or globally;⁸ therefore, the generalizability of the recommendations to the Canadian context is unclear.

Summary of Findings

The recommendations regarding the use of preoperative interventions for the prevention of SSIs from the six included evidence-based guidelines are highlighted below.¹^,⁸^–¹² Detailed summaries of the recommendations and the evidence on which the recommendations were based are presented in Appendix 4.

Guidelines

Recommendations Regarding S. aureus and/or Antimicrobial Resistance Screening

Two identified evidence-based guidelines provided recommendations regarding preoperative S. aureus and/or antimicrobial resistance screening.¹¹^,¹² The APSIC and ACS guidelines recommend that hospitals evaluate their baseline S. aureus, methicillin-resistant S. aureus (MRSA), and SSI rates to determine if the implementation of S. aureus screening and decolonization procedures is appropriate.¹¹^,¹² Furthermore, the APSIC guideline recommends that surveillance on mupirocin resistance rates should be taken into consideration when implementing decolonization measures.¹¹ The APSIC recommendations¹¹ were rated B in strength and were based on level II evidence, while the ACS guideline¹² did not report the recommendation strength or evidence level.

Recommendations Regarding Nasal Decolonization and Preoperative Body Washing

Four identified evidence-based guidelines provided recommendations regarding nasal decolonization,⁸^,⁹^,¹¹^,¹² and five provided recommendations on preoperative body washing.¹^,⁸^,⁹^,¹¹^,¹²

Regarding nasal decolonization, the NICE guideline recommends considering using nasal decolonization with mupirocin along with preoperative body washing with chlorhexidine gluconate (CHG) if S. aureus is a likely cause of SSIs (recommendation strength: consider; evidence level: very low to high).⁹^,¹⁴ The APSIC and WHO guidelines recommend nasal decolonization with mupirocin 2% ointment, with or without CHG body washing, for cardiothoracic and orthopedic surgical patients with known S. aureus nasal carriage (recommendation strength: A or strong; evidence level: I or moderate).⁸^,¹¹ The WHO guideline states that this recommendation can also be considered for other surgical procedures (recommendation strength: conditional; evidence level: moderate).⁸ The ACS guideline recommends clinicians consider using nasal mupirocin, with or without CHG body washing (strength of recommendation and level of evidence not reported).¹² For SSI bundles to be effective, interventions should be adhered to and performed close to surgery date (strength of recommendation and level of evidence not reported).¹² The CDC did not make recommendations regarding nasal decolonization.¹

Regarding preoperative body washing, four guidelines (APSIC, NICE, CDC, and WHO) recommend surgical patients bathe with soap before their procedure.¹^,⁸^,⁹^,¹¹ These recommendations ranged from conditional to strong and were based on evidence that ranged in quality from very low to moderate where reported (evidence level not reported in the NICE guideline).¹^,⁸^,⁹^,¹¹ Three guidelines (APSIC, CDC, and WHO) state that patients can use antimicrobial or non-antimicrobial soap for their preoperative bath (recommendation strength ranged from conditional to strong; evidence level ranged from very low to moderate).¹^,⁸^,¹¹ Due to uncertainty in the available evidence, the CDC and WHO were not able to make recommendations regarding the use of CHG washcloths.¹^,⁸ Furthermore, the ACS guideline highlighted that body washing with CHG, when not part of an SSI bundle, reduces skin pathogen levels but not SSI rates (strength of recommendation and level of evidence not reported).¹²

Recommendations Regarding Skin Antiseptic Preparation

Four identified evidence-based guidelines provided recommendations regarding preoperative skin antisepsis.⁸^,⁹^,¹¹^,¹² Unless contraindicated, alcohol-based skin antiseptic solutions should be used to prepare the surgical site prior to incision as per APSIC, NICE, WHO, and ACS guidelines (recommendation strength was A or strong; evidence level ranged from very low to high where reported; recommendation strength and evidence level not reported in the ACS guideline).⁸^,⁹^,¹¹^,¹² Contraindications to the use of alcohol-based solutions may include surgical sites close to or involving mucous membrane,⁹^,¹² cornea,¹² or ear.¹² Three guidelines made recommendations on the specific types of skin antiseptic solutions to use.⁸^,⁹^,¹² As the first choice for skin antisepsis, the NICE⁹ and WHO⁸ guidelines recommend using alcohol-based CHG solutions, while the ACS¹² guideline recommends alcohol-based CHG or iodine solutions (recommendation strength was strong; evidence level ranged from very low to high where reported; recommendation strength not reported in the ACS and NICE guidelines and evidence level not reported in the ACS guideline). If alcohol-based CHG solutions are contraindicated, the NICE guideline recommends using alcohol-based povidone-iodine, aqueous CHG, or aqueous povidone-iodine solutions (strength of recommendation: not reported; evidence levels: very low to high).⁹ Similarly, if alcohol-based solutions are contraindicated, the ACS guideline also recommends aqueous CHG over the use of aqueous iodine solutions (strength of recommendation and level of evidence not reported).¹²

Recommendations Regarding Hair Removal

Four identified evidence-based guidelines provided recommendations regarding preoperative hair removal.⁸^,⁹^,¹¹^,¹² The APSIC, NICE, ACS, and WHO guidelines recommend that hair should not be removed unless absolutely needed due to interference with the surgical procedure (recommendation strength was B or strong; evidence level ranged from III to moderate where reported; recommendation strength not reported in the ACS guideline and evidence level not reported in the ACS and NICE guidelines).⁸^,⁹^,¹¹^,¹² Specifically, clippers should be used while razors should be avoided as per APSIC, NICE, ACS, and WHO guidelines (recommendation strength was A or strong; evidence level was I or moderate where reported; recommendation strength not reported in the ACS guideline and evidence level not reported in the ACS and NICE guidelines).⁸^,⁹^,¹¹^,¹² As for the timing of hair removal, the NICE guideline⁹ recommends that it be performed on the day of surgery (recommendation strength: strong; evidence level: not reported), while the APSIC guideline¹¹ states that no recommendation can be made (recommendation strength: C; evidence level: III).

Recommendations Regarding Mechanical Bowel Preparation

Four identified evidence-based guidelines provided recommendations regarding preoperative mechanical bowel preparation.⁸^,⁹^,¹¹^,¹² The APSIC, ACS, and WHO guidelines recommend the use of mechanical bowel preparation combined with oral antibiotics for elective colorectal surgical patients (recommendation strength A or conditional; evidence level was I or moderate where reported; recommendation strength and evidence level not reported in the ACS guideline),⁸^,¹¹^,¹² and the WHO guideline recommends against using mechanical bowel preparation alone without oral antibiotics for this population (recommendation strength: strong; evidence level: moderate). However, the NICE guideline recommends against the routine use of mechanical bowel preparation to help prevent SSIs, but did not specify the specific indication or whether this was irrespective of oral antibiotic use (recommendation strength: strong; evidence level: not reported).⁹

Recommendations Regarding Glucose Control

Two identified evidence-based guidelines provided recommendations regarding preoperative glucose control immediately prior to surgery.¹^,¹² The ACS guideline recommends maintaining perioperative blood glucose levels between 110 to 150 mg/dL (6.1 to 8.3 mmol/L) for all patients living with or without diabetes and less than 180 mg/dL (10.0 mmol/L) for patients undergoing cardiac surgery (strength of recommendation and level of evidence not reported).¹² Furthermore, the ACS guideline states that blood glucose targets of less than 110 mg/dL (6.1 mmol/L) increase the risk of hypoglycemia without reducing the rates of SSIs (strength of recommendation and level of evidence not reported).¹² The CDC guideline recommends maintaining blood glucose levels under 200 mg/dL (11.1 mmol/L) without regard for diabetes status (recommendation strength: strong; evidence level: A).¹ Due to the lack of evidence from RCTs, the CDC was not able to make recommendations regarding lower glucose targets, or regarding the optimal timing, duration, or delivery method of glucose control interventions.¹

Recommendations Regarding Antibiotic Prophylaxis

Six identified evidence-based guidelines provided recommendations regarding preoperative antibiotic prophylaxis.¹^,⁸^–¹²

The APSIC and ACS guidelines recommend that, when indicated, antibiotic prophylaxis should be administered within one hour prior to incision, except for vancomycin and fluoroquinolones that need to be given within two hours before incision (recommendation strength: A; evidence level: I where reported; recommendation strength and evidence level not reported in the ACS guideline). The WHO guideline recommends antibiotic prophylaxis be administered within two hours before incision with consideration of the half-life of the antibiotic (recommendation strength: strong; evidence level: moderate).⁸ The NICE guideline recommends considering the administration of a dose of antibiotic prophylaxis intravenously when anesthesia is started (recommendation strength: consider; evidence level: not reported).⁹ The CDC guideline recommends that the administration of parenteral antibiotic prophylaxis should be timed to ensure bactericidal concentration is reached when the incision is made (recommendation strength: strong; evidence level: low to very low-quality); however, no recommendation could be made on specific timing.¹

The CDC guideline recommends that the indication to use parenteral antibiotic prophylaxis should be based on published guidelines (recommendation strength: strong; evidence level: low to very low-quality).¹ Specifically, the CDC recommends that parenteral antibiotic prophylaxis should be given for all cesarean sections (recommendation strength: strong; evidence level: high).¹ The NICE guideline recommends the administration of antibiotic prophylaxis before contaminated procedures, clean-contaminated procedures, or clean procedures that involve prosthesis or implant placement (recommendation strength: strong; evidence level: not reported).⁹ However, the NICE guideline recommends against the routine use of antibiotic prophylaxis for clean non-prosthetic uncomplicated procedures (recommendation strength: strong; evidence level: not reported).⁹

The NICE⁹ guideline recommends that the choice of antibiotic should take into consideration local antibiotic formularies and possible side effects (recommendation strength: strong; evidence level: not reported), while the ACS guideline¹² recommends taking into account the type of surgical procedure and most likely etiological pathogens (strength of recommendation and level of evidence were not reported). Although the CDC guideline¹ was not able to make a recommendation on the effect of weight-adjusted parenteral antibiotic prophylaxis dosing due to the lack of RCTs, the ACS guideline recommends that antibiotic prophylaxis dosing should be weight-adjusted (strength of recommendation and level of evidence was not reported).¹²

The sixth guideline published by the Ministry of Health Malaysia focused on the use of antibiotic prophylaxis for the prevention of oral surgery-related SSIs.¹⁰ The guideline makes grade A recommendations stating that antibiotic prophylaxis is indicated for dental implants (evidence level: I), bone grafts (evidence level: I), clean-contaminated procedures (evidence levels: I, II-2, and III), and head and neck cancers (evidence levels: II-1, II-3, and III).¹⁰ The guideline makes grade B recommendations stating that antibiotic prophylaxis is indicated for medically compromised patients (evidence levels: I, II-2, and III), extended duration procedures (evidence levels: II-2 and III), and facial bone fracture procedures (evidence levels: II-2, II-3, and III).¹⁰ The guideline makes grade B recommendations stating that amoxicillin, penicillin G, or clindamycin (evidence levels: I, II-1, II-3, and III) should be given within one hour before incision (evidence levels: II-2, II-3, and III) and at the full therapeutic dose (evidence levels: II-2 and II-3).¹⁰ Alternatively, cloxacillin, cefazolin or clindamycin should be administered if the procedure involves the skin (recommendation strength: C; evidence level: III).¹⁰

Limitations

One evidence-based guideline was created by oral surgeons and dental health specialists and was focused on the prevention of oral surgery-related SSIs; therefore, these recommendations may not be generalizable to other surgical procedures.¹⁰ Apart from one guideline that is intended for global use,⁸ the other five guidelines were developed for use in the Asia Pacific region,¹¹ Malaysia,¹⁰ United Kingdom,⁹ or United States.¹^,¹² It is uncertain if these guidelines developed outside of Canada are generalizable to the Canadian context. Thus, considering the limitations mentioned, the recommendations summarized in this report need to be interpreted with caution.

Conclusions and Implications for Decision or Policy Making

This report provides a summary and critical appraisal of guidelines identified in a previous CADTH Reference List report;⁵ a companion CADTH report regarding the clinical effectiveness and cost-effectiveness of pre-operative nasal decolonization (with or without chlorhexidine gluconate washes or wipes) for the prevention of surgical site infections is published elsewhere.¹⁵ This report included six evidence-based guidelines regarding the use of preoperative interventions for the prevention of SSIs.¹^,⁸^–¹² One guideline published by the University of Toronto’s Best Practice in Surgery¹⁶ was excluded from this report due to unclear methodology (see Appendix 5). Informed partly by the WHO⁸ and NICE⁹ guidelines, this guideline included similar recommendations on nasal decolonization, skin antisepsis, hair removal, and antibiotic prophylaxis tailored for University of Toronto affiliated hospitals.¹⁶

Of the included guidelines, four recommend nasal decolonization with mupirocin and body washing with CHG.⁸^,⁹^,¹¹^,¹² Additionally, four guidelines recommend bathing with antimicrobial or non-antimicrobial soap before surgery.¹^,⁸^,⁹^,¹¹ Two guidelines recommend taking into account the rates of S. aureus, MRSA, SSIs, and/or mupirocin resistance in the implementation of screening and decolonization measures.¹¹^,¹² Four guidelines recommend alcohol-based solutions for skin antisepsis and recommend against hair removal.⁸^,⁹^,¹¹^,¹² Three guidelines⁸^,¹¹^,¹² recommend mechanical bowel preparation with oral antibiotics for elective colorectal surgery, while one guideline⁹ recommends against its routine use but did not specify for which indications and did not mention oral antibiotic use. Two guidelines recommend maintaining perioperative blood glucose levels at 110 to 150 mg/dL (6.1 to 8.3 mmol/L)¹² or below 200 mg/dL (11.1 mmol/L)¹ without regard for diabetic status. Four guidelines recommend administering antibiotics at one¹¹^,¹² or two⁸ hours prior to incision, or at the time of anesthesia.⁹ Focusing on antibiotic prophylaxis for oral surgical procedures, one guideline recommends the use of amoxicillin, penicillin G, or clindamycin, or cloxacillin, cefazolin, or clindamycin for procedures involving the skin.¹⁰

Overall, these recommendations ranged from conditional to strong and were based on evidence that ranged in quality from very low to high where reported (recommendation strength and/or evidence level was not reported for all ACS recommendations and some NICE recommendations).¹^,⁸^–¹² In general, there was agreement across guidelines for the use of preoperative interventions for the prevention of SSIs; however, the variation in the strengths of recommendations and heterogeneity in the quality of evidence should be considered when interpreting the findings of this report. Guidelines developed with rigorous methodology that are specific to the Canadian context would provide additional guidance in preventing SSIs in a more local context.

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26.: Anderson DJ, Podgorny K, Berríos-Torres SI, et al. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(6):605–627. [PMC free article: PMC4267723] [PubMed: 24799638]
27.: Webster J, Osborne S. Preoperative bathing or showering with skin antiseptics to prevent surgical site infection. Cochrane Database Syst Rev. 2012(9). [PubMed: 22972080]
28.: Walsh EE, Greene L, Kirshner R. Sustained reduction in methicillin-resistant Staphylococcus aureus wound infections after cardiothoracic surgery. Arch Intern Med. 2011;171(1):68–73. [PubMed: 20837818]
29.: Schweizer ML, Chiang H-Y, Septimus E, et al. Association of a bundled intervention with surgical site infections among patients undergoing cardiac, hip, or knee surgery. JAMA. 2015;313(21):2162–2171. [PubMed: 26034956]
30.: Awad SS, Palacio CH, Subramanian A, et al. Implementation of a methicillin-resistant Staphylococcus aureus (MRSA) prevention bundle results in decreased MRSA surgical site infections. Am J Surg. 2009;198(5):607–610. [PubMed: 19887186]
31.: Reichman DE, Greenberg JA. Reducing surgical site infections: a review. Rev Obstet Gynecol. 2009;2(4):212–221. [PMC free article: PMC2812878] [PubMed: 20111657]
32.: Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control. 1999;27(2):97–132; quiz 133-134; discussion 196. [PubMed: 10196487]
33.: Sidhwa F, Itani KMF. Skin Preparation Before Surgery: Options and Evidence. Surg Infect. 2015;16(1):14–23. [PubMed: 25761076]
34.: Cataife G, Weinberg DA, Wong HH, Kahn KL. The effect of Surgical Care Improvement Project (SCIP) compliance on surgical site infections (SSI). Med Care. 2014;52(2 Suppl 1):S66–73. [PubMed: 24430269]
35.: Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect. 2013;14(1):73–156. [PubMed: 23461695]
36.: Vriesendorp TM, Morélis QJ, DeVries JH, Legemate DA, Hoekstra JBL. Early post-operative glucose levels are an independent risk factor for infection after peripheral vascular surgery. A retrospective study. Eur J Vasc Endovasc Surg. 2004;28(5):520–525. [PubMed: 15465374]
37.: Lazar HL, McDonnell MM, Chipkin S, Fitzgerald C, Bliss C, Cabral H. Effects of aggressive versus moderate glycemic control on clinical outcomes in diabetic coronary artery bypass graft patients. Ann Surg. 2011;254(3):458–464. [PubMed: 21865944]
38.: Kwon S, Thompson R, Dellinger P, Yanez D, Farrohki E, Flum D. Importance of perioperative glycemic control in general surgery: a report from the surgical care and outcomes assessment program. Ann Surg. 2013;257(1):8–14. [PMC free article: PMC4208433] [PubMed: 23235393]
39.: Kotagal M, Symons RG, Hirsch IB, et al. Perioperative hyperglycemia and risk of adverse events among patients with and without diabetes. Ann Surg. 2015;261(1):97–103. [PMC free article: PMC4208939] [PubMed: 25133932]
40.: Kirdemir P, Yildirim V, Kiris I, et al. Does continuous insulin therapy reduce postoperative supraventricular tachycardia incidence after coronary artery bypass operations in diabetic patients? J Cardiothorac Vasc Anesth. 2008;22(3):383–387. [PubMed: 18503925]
41.: Grey NJ, Perdrizet GA. Reduction of nosocomial infections in the surgical intensive-care unit by strict glycemic control. Endocr Pract. 2004;10(SUPPL. 2):46–52. [PubMed: 15251640]
42.: Emam IA, Allan A, Eskander K, et al. Our experience of controlling diabetes in the peri-operative period of patients who underwent cardiac surgery. Diabetes Res Clin Pract. 2010;88(3):242–246. [PubMed: 20395003]
43.: Desai SP, Henry LL, Holmes SD, et al. Strict versus liberal target range for perioperative glucose in patients undergoing coronary artery bypass grafting: a prospective randomized controlled trial. J Thoracic Cardiovasc Surg. 2012;143(2):318–325. [PubMed: 22137804]
44.: Chan RPC, Galas FRBG, Hajjar LA, Bello CN, Piccioni MA, Auler Jr JOC. Intensive perioperative glucose control does not improve outcomes of patients submitted to open-heart surgery: a randomized controlled trial. Clinics. 2009;64(1):51–60. [PMC free article: PMC2671976] [PubMed: 19142552]
45.: Bratzler DW, Hunt DR. The Surgical Infection Prevention and Surgical Care Improvement projects: national initiatives to improve outcomes for patients having surgery. Clin Infect Dis. 2006;43(3):322–330. [PubMed: 16804848]
46.: Bilotta F, Spinelli A, Giovannini F, Doronzio A, Delfini R, Rosa G. The effect of intensive insulin therapy on infection rate, vasospasm, neurologic outcome, and mortality in neurointensive care unit after intracranial aneurysm clipping in patients with acute subarachnoid hemorrhage: A randomized prospective pilot trial. J Neurosurg Anesthesiol. 2007;19(3):156–160. [PubMed: 17592345]
47.: Ata A, Lee J, Bestle SL, Desemone J, Stain SC. Postoperative hyperglycemia and surgical site infection in general surgery patients. Arch Surg. 2010;145(9):858–864. [PubMed: 20855756]
48.: Berrios-Torres SI, Umscheid CA, Bratzler DW, et al. Healthcare Infection Control Practices Advisory Committee. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017 (Supplementary online content). JAMA Surg. 2017 May 3 (online publication);152(8).
49.: World Health Organization. WHO Surgical site infection prevention guidelines web appendix 2: summary of a systematic review on preoperative bathing Geneva, Switzerland: WHO; 2016: https://www.who.int/infection-prevention/tools/surgical/appendix2.pdf?ua=1. Accessed 2020 May 21.
50.: World Health Organization. WHO Surgical site infection prevention guidelines web appendix 3: summary of a systematic review on decolonization with mupirocin ointment with or without chlorhexidine gluconate body wash for the prevention of Staphylococcus aureus infection in nasal carriers undergoing surgery. Geneva, Switzerland: WHO; 2016: https://www.who.int/gpsc/appendix3.pdf?ua=1. Accessed 2020 May 21.
51.: World Health Organization. WHO global guidelines for the prevention of surgical site infection web appendix 5: summary of a systematic review on optimal timing for preoperative surgical antibiotic prophylaxis. Geneva, Switzerland: WHO; 2016: https://www.who.int/gpsc/Appendix5.pdf?ua=1. Accessed 2020 May 21. [PubMed: 27929621]
52.: World Health Organization. WHO Surgical site infection prevention guidelines web appendix 6: summary of a systematic review on mechanical bowel preparation and the use of oral antibiotics. Geneva, Switzerland: WHO; 2016: https://www.who.int/gpsc/appendix6.pdf?ua=1. Accessed 2020 May 21.
53.: World Health Organization. WHO Surgical site infection prevention guidelines web appendix 7: summary of a systematic review on the effectiveness and optimal method of hair removal. Geneva, Switzerland: WHO; 2016: https://www.who.int/gpsc/appendix7.pdf?ua=1. Accessed 2020 May 21.
54.: World Health Organization. WHO Surgical site infection prevention guidelines web appendix 8: summary of a systematic literature review on surgical site preparation. Geneva, Switzerland: WHO; 2016: https://www.who.int/gpsc/appendix8.pdf?ua=1. Accessed 2020 May 21.

Abbreviations

AGREE II: Appraisal of Guidelines for Research & Evaluation 2
CDC: Centers for Disease Control and Prevention
CHG: Chlorhexidine gluconate
GRADE: Grading of Recommendations, Assessment, Development, and Evaluation
MRSA: methicillin-resistant Staphylococcus aureus
NICE: National Institute for Health and Care Excellence
RCT: Randomized controlled trial
S. aureus: Staphylococcus aureus
SR: Systematic Review
SSI: Surgical site infection

Appendix 1. Selection of Included Studies

Appendix 2. Characteristics of Included Publications

Table 2. Characteristics of Included Guideline

Appendix 3. Critical Appraisal of Included Publications

Table 3. Strengths and Limitations of Guidelines using AGREE II

Appendix 4. Main Study Findings and Authors’ Conclusions

Table 4. Summary of Recommendations in Included Guidelines (PDF, 519K)

Appendix 5. Additional References of Potential Interest

Previous CADTH Reports

1.: Li KX, Grobelna A. Decolonization for the treatment of methicillin resistant staphylococcus aureus: clinical effectiveness and guidelines [CADTH rapid response report: reference list]. Ottawa (ON): CADTH; 2019 Jan: https://cadth.ca/sites/default/files/pdf/htis/2019/RA1005%20ARO%20Decolonization%20Final.pdf Accessed 2020 Mar 3. [PubMed: 31693327]
2.: Banerjee S, Argáez C. Topical antibiotics for infection prevention: a review of the clinical effectiveness and guidelines [CADTH rapid response report: summary with critical appraisal]. Ottawa (ON): CADTH; 2017 Mar: https://www.ncbi.nlm.nih.gov/books/NBK487430/ Accessed 2020 Mar 3. [PubMed: 29533570]
3.: Chlorhexidine gluconate wipes for infection prevention in acute and critical care: a review of clinical effectiveness and cost-effectiveness [CADTH rapid response report: summary with critical appraisal]. Ottawa (ON): CADTH; 2016 Apr: https://cadth.ca/sites/default/files/pdf/htis/apr-2016/RC0769%20Chlorhexidine%20Wipes%20Final.pdf Accessed 2020 Mar 3. [PubMed: 27227206]

Overview of Systematic Reviews

4.: Gillespie BM, Walker RM, McInnes E, et al. Preoperative and postoperative recommendations to surgical wound care interventions: a systematic meta-review of Cochrane reviews. Int J Nurs Stud. 2020 Feb;102:103486. PubMed: PM31810020 [PubMed: 31810020]

Guidelines

Unclear Methodology

5.: Consensus guideline on preoperative antibiotics and surgical site infection in breast surgery. Columbia (MD): The American Society of Breast Surgeons; 2018: https://www.breastsurgeons.org/docs/statements/Consensus-Guideline-on-Preoperative-Antibiotics-and-Surgical-Site-Infection-in-Breast-Surgery.pdf Accessed 2020 Mar 3.
6.: Bonnar P, Dhar P, Rotstein O, et al. Surgical site infection prevention. Toronto (ON): University of Toronto Best Practice in Surgery; 2017 Sep: http://bestpracticeinsurgery.ca/wp-content/uploads/2017/11/SSI-BPS-CPG-Nov20.pdf Accessed 2020 Mar 3.
7.: Centre for Health Protection. Recommendations on prevention of surgical site infection. 2^nd ed. Kowloon, Hong Kong: Scientific Committee on Infection Control, and Infection Control Branch, Centre for Health Protection, Department of Health; 2017 Sep: https://www.chp.gov.hk/files/pdf/recommendations_on_prevention_of_surgical_site_infection_2nd_edition.pdf Accessed 2020 Mar 3.

Summary of WHO 2016 Guideline

8.: Allegranzi B, Bischoff P, de Jonge S, et al. New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis. 2016 Dec;16(12):e276–e287. PubMed: PM27816413 [PubMed: 27816413]

Alternative Intervention

9.: Don’t order peri-operative antibiotics beyond a 24-hour post-operative period for non-complicated instrumented cases in patients who are not at high risk for infection or wound contamination. Administration of a single preoperative dose for spine cases without instrumentation is adequate. Toronto (ON): Choosing Wisely Canada; 2019 Jul: https://choosingwiselycanada.org/spine/ Accessed 2020 Mar 3.

About the Series

CADTH Rapid Response Report: Summary with Critical Appraisal

ISSN: 1922-8147

Version: 1.0

Funding: CADTH receives funding from Canada’s federal, provincial, and territorial governments, with the exception of Quebec.

Suggested citation:

Preoperative interventions for the prevention of surgical site infections: a review of guidelines. Ottawa: CADTH; 2020 Jun. (CADTH rapid response report: summary with critical appraisal).

Disclaimer: The information in this document is intended to help Canadian health care decision-makers, health care professionals, health systems leaders, and policy-makers make well-informed decisions and thereby improve the quality of health care services. While patients and others may access this document, the document is made available for informational purposes only and no representations or warranties are made with respect to its fitness for any particular purpose. The information in this document should not be used as a substitute for professional medical advice or as a substitute for the application of clinical judgment in respect of the care of a particular patient or other professional judgment in any decision-making process. The Canadian Agency for Drugs and Technologies in Health (CADTH) does not endorse any information, drugs, therapies, treatments, products, processes, or services.

While care has been taken to ensure that the information prepared by CADTH in this document is accurate, complete, and up-to-date as at the applicable date the material was first published by CADTH, CADTH does not make any guarantees to that effect. CADTH does not guarantee and is not responsible for the quality, currency, propriety, accuracy, or reasonableness of any statements, information, or conclusions contained in any third-party materials used in preparing this document. The views and opinions of third parties published in this document do not necessarily state or reflect those of CADTH.

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Context and Policy Issues
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Key Findings
Methods
Summary of Evidence
Conclusions and Implications for Decision or Policy Making
References
Abbreviations
Selection of Included Studies
Characteristics of Included Publications
Critical Appraisal of Included Publications
Main Study Findings and Authors’ Conclusions
Additional References of Potential Interest

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Preoperative Interventions for the Prevention of Surgical Site Infections: A Review of Guidelines

Context and Policy Issues

Research Question

Key Findings

Methods

Literature Search Methods

Selection Criteria and Methods

Table 1

Exclusion Criteria

Critical Appraisal of Individual Studies

Summary of Evidence

Quantity of Research Available

Summary of Study Characteristics

Study Design

Country of Origin

Patient Population

Interventions and Comparators

Outcomes

Summary of Critical Appraisal

Summary of Findings

Guidelines

Recommendations Regarding S. aureus and/or Antimicrobial Resistance Screening

Recommendations Regarding Nasal Decolonization and Preoperative Body Washing

Recommendations Regarding Skin Antiseptic Preparation

Recommendations Regarding Hair Removal

Recommendations Regarding Mechanical Bowel Preparation

Recommendations Regarding Glucose Control

Recommendations Regarding Antibiotic Prophylaxis

Limitations

Conclusions and Implications for Decision or Policy Making

References

Abbreviations

Appendix 1. Selection of Included Studies

Appendix 2. Characteristics of Included Publications

Appendix 3. Critical Appraisal of Included Publications

Appendix 4. Main Study Findings and Authors’ Conclusions

Appendix 5. Additional References of Potential Interest

Previous CADTH Reports

Overview of Systematic Reviews

Guidelines

Unclear Methodology

Summary of WHO 2016 Guideline

Alternative Intervention

About the Series

Suggested citation:

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In this Page

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