What The New WHO Recommendations Emphasize On Preoperative Measures For Preventing Surgical Site Infection
Surgical site infections (SSI) are the second most common cause of healthcare-associated infections in the United States.1,2 The most recent study on the incidence of healthcare-associated infections in the United States examined data from the National Nosocomial Infections Surveillance (NNIS) system from 1990 to 2002 and estimated 1.7 million infections with 20 percent of these being SSIs.2
These infections are a significant source of morbidity, mortality and increased healthcare costs. In response to the lack of international guidelines and inconsistent national guidelines, the World Health Organization (WHO) recently released new recommendations on preoperative (part 1), intraoperative and postoperative measures (part 2) for the prevention of SSIs.3,4
Part 1 of the new WHO recommendations provides 13 preoperative measures, 11 of which are relevant to the foot and ankle surgeons, to prevent surgical site infections.3 An expert panel formulated these evidence-based recommendations and all members of surgical teams including physicians and staff are expected to implement them. The following recommendations are the WHO-recommended preoperative measures for the prevention of SSI.3
Recommendation 1: Do not discontinue immunosuppressive medication preoperatively to prevent SSI. Research has not shown that discontinuation of immunosuppressive medications lowers the incidence of SSI.5 Additionally, discontinuation of therapy has the risk of potentially causing disease flare-ups and other perioperative morbidities.
Recommendation 2: Consider the administration of multiple nutrient-enhanced nutritional formulas to prevent SSI in underweight patients undergoing major surgical procedures. Research has shown that nutritional status affects host immunity and malnutrition can make individuals significantly more susceptible to postoperative infections.6-8 Numerous surgical specialties have shown a link between patients’ preoperative nutritional status and postoperative complications.6-8 Early nutritional therapy may improve surgical outcomes and decrease the risk of SSI in malnourished patients.9,10 Researchers have demonstrated that multiple nutrient-enhanced formulas (containing any combination of arginine, glutamine, omega-3 fatty acids and nucleotides) can significantly decrease SSI in comparison to standard formulas and single nutrient-enhanced formulas.3
Recommendation 3: Patients should bathe or shower with plain or antimicrobial soap prior to surgery. Preoperative bathing can help reduce SSI by decreasing bacterial load. Bathing with antimicrobial soap containing chlorhexidine gluconate is no more effective than plain soap in reducing SSI.3
Recommendations 4 and 5: Known nasal carriers of Staph aureus undergoing orthopedic, cardiothoracic and other surgery should undergo perioperative decolonization with an intranasal mupirocin ointment. S. aureus nasal carriage is a well defined risk factor for SSI.11 One can eradicate nasal carriage with the use of 2% mupirocin ointment applied twice daily for five days.12,13 Patients often combine body wash with chlorhexidine gluconate soap for full body decolonization.13 The WHO recommends that all patients undergoing orthopedic surgery who are known S. aureus carriers undergo decolonization with nasal mupirocin with or without chlorhexidine gluconate body wash. Currently, there is insufficient data to establish cost-effective screening protocols to identify nasal carriers of S. aureus.
Recommendations 6 and 7: (The use of mechanical bowel preparation and oral antibiotics for gastrointestinal surgery are not applicable to foot and ankle surgeons).
Recommendation 8: Patients undergoing any surgical procedure should either not have hair removed or, if absolutely necessary, have hair removed with clippers. The WHO strongly discourages shaving both preoperatively and in the operating room. While some have perceived hair as poor cleanliness causing an increased risk of SSI, studies have shown that not removing hair does not increase the risk of SSI.14 Studies have found that shaving can cause microscopic skin trauma, which increases the risk of SSI.15 Preoperative hair clipping does not increase the risk of SSI and one can perform this if necessary for surgical site visualization.16
Recommendations 9 and 10: Administer surgical antibiotic prophylaxis within 120 minutes prior to incision time with consideration for the antibiotic half-life and duration of surgery. To be effective, one must deliver prophylactic antibiotics to the surgical site at appropriate levels prior to incision and throughout the surgical procedure. Administration of surgical antibiotic prophylaxis more than 120 minutes prior to incision as well as after the incision has been associated with a significantly higher incidence of SSI.3 Comparisons of surgical antibiotic prophylaxis administration 30, 60 and 120 minutes prior to incision showed no significant reduction in SSI incidence among these various timeframes.3 Consider the time needed to complete the procedure as well as the half-life of the antibiotic to help determine optimal administration time. For long surgical procedures and when using an antibiotic with a short half-life (cefazolin), administer antibiotics closer (less than 60 minutes) to the incision time.
Recommendation 11: Surgical hand preparation should occur either by scrubbing with appropriate antimicrobial soap and water, or using a suitable alcohol-based hand rub prior to donning sterile gloves. Preoperative surgical hand preparation is vitally important to reduce surgical site contamination and lower the incidence of SSI. In 2009, the WHO issued recommendations on surgical hand preparation in their guidelines on hand hygiene in healthcare.17 Researchers have found no significant difference in the incidence of SSI in comparing alcohol-based hand rub to scrubbing with antimicrobial soap (4% povidone-iodine or 4% chlorhexidine gluconate).3 When looking at bacterial loads, alcohol-based hand rubs are more effective than scrubbing with antimicrobial soap in reducing colony-forming units but the effect of this on reducing the incidence of SSI is unknown.18,19
Recommendation 12: Use chlorhexidine gluconate with alcohol-based antiseptic solutions for surgical site skin preparation. Surgical site skin preparation reduces microbial load, limits wound contamination and is effective in preventing surgical site infection.20 Common skin preparations include chlorhexidine gluconate and povidone-iodine in alcohol or aqueous-based solutions. The WHO’s meta-analysis shows alcohol-based solutions to be more effective than aqueous solutions in reducing SSI.3 Additionally, WHO found chlorhexidine gluconate alcohol-based solutions to be superior to povidone-iodine alcohol-based solutions in reducing the incidence of SSI.3
Recommendation 13: Do not use antimicrobial skin sealants after surgical site skin preparation to reduce SSI. Surgeons have used cyanoacrylate-based skin sealants as an additional antiseptic measure to prevent migration of skin flora to the surgical site and seal any dermal microabrasions to prevent surgical site re-colonization. A recent Cochrane review and the WHO meta-analysis showed no reduction in SSI with the use of these antimicrobial sealants in comparison to standard surgical site skin preparation only.3,21 The WHO recommends avoiding the use of antimicrobial sealants to reduce unnecessary surgical costs.
The WHO’s new recommendations provide a much needed, uniform set of evidence-based measures to reduce SSI. The following month’s blog will review part 2 of the WHO recommendations: intraoperative and postoperative measures for the prevention of SSI.
References
1. World Health Organization. Report on the Burden of Endemic Health Care-Associated Infection Worldwide. World Health Organization, Geneva, 2011.
2. Klevens RM, Edwards JR, Richards CL, Jr., et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007;122(2):160-166.
3. 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; epub Nov. 1
4. Allegranzi B, Zayed B, Bischoff P, et al. New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis. 2016.
5. Sreekumar R, Gray J, Kay P, Grennan DM. Methotrexate and post operative complications in patients with rheumatoid arthritis undergoing elective orthopaedic surgery--a ten year follow-up. Acta Orthop Belg. 2011;77(6):823-826.
6. Burden S, Todd C, Hill J, Lal S. Pre-operative nutrition support in patients undergoing gastrointestinal surgery. Cochrane Database Syst Rev. 2012;11:CD008879.
7. Salvetti DJ, Tempel ZJ, Gandhoke GS, et al. Preoperative prealbumin level as a risk factor for surgical site infection following elective spine surgery. Surg Neurol Int. 2015;6(Suppl 19):S500-503.
8. Del Savio GC, Zelicof SB, Wexler LM, et al. Preoperative nutritional status and outcome of elective total hip replacement. Clinical orthopaedics and related research. 1996(326):153-161.
9. Culebras JM. Malnutrition in the twenty-first century: an epidemic affecting surgical outcome. Surg Infect (Larchmt). 2013;14(3):237-243.
10. Di Carlo V, Gianotti L, Balzano G, Zerbi A, Braga M. Complications of pancreatic surgery and the role of perioperative nutrition. Dig Surg. 1999;16(4):320-326.
11. Levy PY, Ollivier M, Drancourt M, Raoult D, Argenson JN. Relation between nasal carriage of Staphylococcus aureus and surgical site infection in orthopedic surgery: the role of nasal contamination. A systematic literature review and meta-analysis. Orthoped Traumatol Surg Res. 2013;99(6):645-651.
12. Coates T, Bax R, Coates A. Nasal decolonization of Staphylococcus aureus with mupirocin: strengths, weaknesses and future prospects. J Antimicrob Chemother. 2009;64(1):9-15.
13. McConeghy KW, Mikolich DJ, LaPlante KL. Agents for the decolonization of methicillin-resistant Staphylococcus aureus. Pharmacotherapy. 2009;29(3):263-280.
14. Lefebvre A, Saliou P, Lucet JC, et al. Preoperative hair removal and surgical site infections: network meta-analysis of randomized controlled trials. J Hosp Infect. 2015;91(2):100-108.
15. Adisa AO, Lawal OO, Adejuyigbe O. Evaluation of two methods of preoperative hair removal and their relationship to postoperative wound infection. J Infect Dev Ctries. 2011;5(10):717-722.
16. Kowalski TJ, Kothari SN, Mathiason MA, Borgert AJ. Impact of hair removal on surgical site infection rates: a prospective randomized noninferiority trial. J Am Coll Surg. 2016;223(5):704-711.
17. World Health Organization. WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge Clean Care Is Safer Care. Geneva, 2009.
18. Hsieh HF, Chiu HH, Lee FP. Surgical hand scrubs in relation to microbial counts: systematic literature review. J Adv Nurs. 2006;55(1):68-78.
19. Tanner J, Dumville JC, Norman G, Fortnam M. Surgical hand antisepsis to reduce surgical site infection. Cochrane Database Syst Rev. 2016(1):CD004288.
20. Ostrander RV, Botte MJ, Brage ME. Efficacy of surgical preparation solutions in foot and ankle surgery. J Bone Joint Surg Am. 2005;87(5):980-985.
21. Wood C, Phillips C. Cyanoacrylate microbial sealants for skin preparation prior to surgery. Cochrane Database Syst Rev. 2016(5):CD008062.
