|Year : 2018 | Volume
| Issue : 1 | Page : 1-12
A review of prevention of surgical site infections in Indian hospitals based on global guidelines for the prevention of surgical site infection, 2016
A Arora1, P Bharadwaj2, H Chaturvedi3, P Chowbey4, S Gupta5, D Leaper6, GK Mani7, SK S Marya8, R Premnath9, K Quadros10, A Srivastava11, A Tendolkar12
1 MD Head-Quality and Patient Safety at Fortis Healthcare Limited, Delhi, India
2 Senior Consultant, Obstetrics and Gynaecology, Minimal Invasive Gynaecology Royal Free Hospital, London, Robotic Training IRCAD, Strasbourg, France, Day Care Endoscopy Birmingham City Hospital, Birmingham, UK, Diploma Operative Pelviscopy Kiel, Germany
3 Chairman, Max Institute of Cancer care, New Delhi, India
4 MBBS, MS, MNAMS, FRCS (LONDON) FIMSA, FAIS, FICS, FACS, FIAGES, FALS, Chairman Max Institute of Minimal Access, Metabolic and Bariatric Surgery, Executive Vice Chairman at Max Healthcare, New Delhi, India
5 MBBS, MHA, FNAMS, FIHE, FAHA, Medical Superintendent, All India Institute of Medical Sciences, New Delhi, India
6 DSc MD ChM FRCS FACS FLS, Emeritus Professor of Surgery, University of Newcastle upon Tyne, Emeritus Professor of Clinical Sciences, ISIaIP, University of Huddersfield, Visiting Professor, Imperial College, London, UK
7 Chairman (Heart Surgery), Max Smart Super Speciality Hospital, New Delhi, India
8 Chairman of Bone and Joints Institute at Medanta Hospital, Karnataka, India
9 Head of Department of Day Care Surgery at Ramakrishna Group of Hospitals in Bangalore, Karnataka, India
10 DGO, MD (OBGY), Diploma in Endoscopy, UK, USA
11 Head, Department of Surgical Disciplines, AIIMS, New Delhi, India
12 Consultant Cardiovascular Thoracic Surgeon, Mumbai, Maharashtra, India
|Date of Web Publication||6-Aug-2018|
Dr. G K Mani
Max Smart Super Speciality Hospital, New Delhi
Source of Support: None, Conflict of Interest: None
While the global estimates of surgical site infection (SSI) have varied from 0.5% to 15%, studies in India have consistently shown higher rates ranging from 23% to 38%. The incidence of SSI may be influenced by factors such as pre-operative care, the theatre environment, post-operative care and the type of surgery. Many other factors influence surgical wound healing and determine the potential for, and the incidence of, infection. Therefore, the prevention of these infections is complex and requires the integration of a range of preventive measures before, during and after surgery. No standardised guidelines backed by evidence are currently established in India for the prevention of SSI. Hence, there is a need for an adaptable, executable National Guideline for low- and middle-income countries which includes India. An effort to draw out most doable and must doable action points to prevent SSI was undertaken by the panelists involved in this paper on the basis of recent global guidelines for the prevention of SSI.
Keywords: Drain removal, glucose control, hair removal, hand preparation, mechanical bowel preparation, pre-operative bathing, surgical antibiotic prophylaxis, surgical site infection prevention, surgical site preparation, triclosan-coated sutures, wound irrigation
|How to cite this article:|
Arora A, Bharadwaj P, Chaturvedi H, Chowbey P, Gupta S, Leaper D, Mani G K, S Marya S K, Premnath R, Quadros K, Srivastava A, Tendolkar A. A review of prevention of surgical site infections in Indian hospitals based on global guidelines for the prevention of surgical site infection, 2016. J Patient Saf Infect Control 2018;6:1-12
|How to cite this URL:|
Arora A, Bharadwaj P, Chaturvedi H, Chowbey P, Gupta S, Leaper D, Mani G K, S Marya S K, Premnath R, Quadros K, Srivastava A, Tendolkar A. A review of prevention of surgical site infections in Indian hospitals based on global guidelines for the prevention of surgical site infection, 2016. J Patient Saf Infect Control [serial online] 2018 [cited 2019 Oct 18];6:1-12. Available from: http://www.jpsiconline.com/text.asp?2018/6/1/1/238599
| Introduction|| |
Healthcare-associated infections (HAIs) are acquired by patients when receiving care, in both primary and secondary environments and are the most frequent adverse event affecting patient safety worldwide. Although the global burden remains unknown because of the difficulty to gather reliable data, it is estimated that hundreds of millions of patients are affected by HAIs each year, leading to significant mortality and huge financial strain on health systems. At present, no country is free from the burden of disease caused by HAIs and antimicrobial, specifically antibiotic, resistance (AMR). Of every 100 hospitalised patients at any given time, seven in developed and 15 in developing countries will acquire at least one HAI. The endemic burden of HAI is also significantly (at least 2—3 times) higher in low- and middle-income countries (LMICs) than in high-income nations. Recent work by the World Health Organization's (WHO) Clean Care is Safer Care program shows that surgical site infection (SSI) is the most surveyed and frequent type of HAI in LMICs and affects up to one-third of the patients who have undergone a surgical procedure.
In LMICs, the pooled incidence of SSI is 11.8/100 surgical procedures (range 1.2—23.6). SSI is one of the most common post-operative complications and causes significant post-operative morbidity and mortality. While the global estimates of SSI have varied from 0.5% to 15%, studies in India have consistently shown higher rates ranging from 23% to 38%. SSI also poses a significant health economic burden on individual patients. Various studies have reported a high SSI incidence rate in India. A study by Subramanian et al. at the All India Institute of Medical Sciences estimated an infection rate of 24.8%. A similar study by Ganguly et al. in Aligarh reported an infection rate of 38.8%. The incidence of SSI was found to be related to the type of wounds and varied with the operation location. The incidence of SSI was highest after cardiovascular, and gastrointestinal surgery,, and the most common pathogens found in SSIs were Staphylococcus aureus, Pseudomonas aeruginosa and Escherichia coli.,,,,,,,,, The infection rate increased with the order of operation on the operation list.
Extent of the problem
SSIs are common complications which follow all types of operative procedures. Patients who develop an SSI are more likely to have an extended hospital stay with additional economic costs, mainly attributable to the extended length of stay. Indirect costs, such as loss of productivity by the patient and an increased burden on their careers, further add to the economic cost of SSI to healthcare systems. These infections are caused by exogenous (from the environment of the operating theatre or the surgical ward) and endogenous microorganisms (from the patients' own skin or opened viscus) which enter the operative wound during surgery. The incidence of SSI may be influenced by factors such as pre-operative care, the theatre environment, post-operative care and the type of surgery. Many other factors influence surgical wound healing and determine the potential for, and the incidence of, infection. Therefore, the prevention of these infections is complex and requires the integration of a range of preventive measures before, during and after surgery. However, the implementation of these measures is not standardised worldwide. No international/national guidelines are currently established in India for the prevention of SSI and inconsistency in the interpretation of evidence and recommendations among available national guidelines is frequently identified. Hence, there is a need for an adaptable, executable National Guideline for LMICs which includes India.
The primary target audience for these recommendations is the surgical team: surgeons, nurses, technical support staff, anaesthetists and any professionals directly providing surgical care. Pharmacists and sterilisation unit staff will also be involved in some aspects of these guidelines. The recommendations are also intended to be used by policy-makers, senior managers and infection prevention and control professionals as the basis for developing national and local SSI protocols and policies and supporting staff education and training. A diverse group of practitioners was therefore chosen for the Ethicon Advisory Board Panel to represent a wide and holistic view on SSI prevention and include a wide representation of healthcare management professionals with the aim of producing a guideline for better patient services. The primary object of this draft guideline is to make it suitable for all types of hospital. Therefore, the panelists were asked to deliberate on selected recommendations from the recently published WHO guideline for prevention of SSI, keeping in mind the current diverse healthcare environments in India.
| Pre-Operative Interventions|| |
WHO: It is good clinical practice for patients to bathe or shower prior to surgery. The panel suggests that either a plain or antimicrobial soap may be used for this purpose (Conditional recommendation, moderate quality of evidence). The panel decided not to formulate a recommendation on the use of chlorhexidine gluconate (CHG)-impregnated cloths for the purpose of reducing SSI due to the limited and very low-quality evidence.
In India, it is important to start with awareness of basic hygiene, cognizant of variant weather conditions and its impact on hygiene, such as excessive sweating. The panelists agreed that there is no standardisation needed for the type of soap used (liquid or bar, beauty soap or medicated soap) and recommending 'medicated soap' may be a better option. However, on further deliberation with respect to supportive evidence, it was clear that there is little evidence to support 'medicated soap' for SSI reduction. It was suggested that a recommendation equivalent to that suggested by the Centers for Disease Control of the US (CDC) should be used; i.e., 2 baths/showers-one the night before and one on the morning of surgery. It was added that cardiac surgeons should take the precaution to advise their patients to clean axilla, and other areas close to surgical field, with CHG if possible. The panel decided to adopt and follow WHO recommendation for pre-operative bathing.
Summary of the evidence
Nine studies (seven randomised controlled trials [RCTs] and two observational studies), including a total of 17, 087 adult patients,,,,,,,,, investigated pre-operative bathing or showering with an antimicrobial soap compared to plain soap. There is a moderate quality of evidence that bathing with CHG soap does not significantly reduce SSI rates compared to bathing with plain soap (Odds Ratio [OR]: 0.92; 95% confidence interval [CI]: 0.80—1.04). There is very low quality evidence that pre-operative bathing with CHG-impregnated cloths may reduce SSI rates when compared to either bathing with CHG soap or no bathing. The body of retrieved evidence focused on adult patients and no studies were available in the pediatric population. Several organisations, such as National Institute for Health and Care Excellence (NICE) 2008 and 2013; UK High Impact intervention bundle 2011, have issued recommendations regarding pre-operative bathing. Most recommended bathing with soap on the day of the operation or the day before. Only the US Institute of Healthcare Improvement bundle for hip and knee arthroplasty recommends CHG soap for pre-operative bathing.
Optimal timing for pre-operative surgical antibiotic prophylaxis
WHO: The panel recommends the administration of surgical antibiotic prophylaxis (SAP) prior to the surgical incision when indicated (depending on the type of operation) (Strong recommendation, low quality of evidence). The panel recommends the administration of SAP within 120 min before incision, while considering the half-life of the antibiotic (Strong recommendation, moderate quality of evidence).
The irrational use of antibiotics is a major problem of present-day medical practices and its consequences include ineffective treatment, development of resistance to antibiotics, adverse effects and an economic burden on patients and society. Widespread and indiscriminate use of broad-spectrum antibiotics has contributed to the emergence of multidrug resistance. Existing evidence suggests that there is a causal association between antibiotic usage in hospitals and AMR. Appropriate antibiotic prophylaxis has also been shown to be effective in reducing the incidence of SSI. In India, no consistency was noted in the timing of administration of prophylactic antibiotics, and no guidelines are being adhered to regarding prophylactic antibiotic administration. The panel also deliberated on the optimal timing of administration because the timing of administration at f induction of anaesthesia could represent a long-time gap between injection and incision. Other factors pertaining to IV antibiotic administration timing included pharmacokinetics and half-life, type of surgery and duration. For example, the American Society of Health-Care Pharmacists (ASHP) guidelines recommend 15 min before incision. Vancomycin needs a long infusion time 30—60 min which needs matching to incision time. It was decided to agree with the above recommendation from the WHO.,
The panel recommends the administration of the first dose of antimicrobial within 60 min before the surgical incision. The administration of fluoroquinolones and vancomycin should begin within 120 min before surgical incision because of the prolonged infusion times required for these drugs.
Summary of the evidence
A total of 13 observational studies,,,,,,,,,,,,, including a total of 53,975 adult patients, were identified; and 2 were from multiple centres. No RCTs were identified. The evidence focused on adult patients. Moderate quality evidence shows that SAP administration before 120 min pre-incision is associated with a significantly higher risk of SSI when compared to administration within 120 min (OR: 5.26; 95% CI: 3.29—8.39). Furthermore, there is low-quality evidence that the administration of SAP after incision is associated with a significantly higher risk of SSI compared to administration before incision (OR: 1.89; 95% CI: 1.05—3.4). In addition, low-quality evidence shows that the administration within 60 min before incision has neither benefit nor harm for the reduction of SSI rates compared to administration between 60 and 120 min before incision. Similarly, SAP administration within 30-0 min before incision has neither benefit nor harm for the reduction of SSI rates when compared to administration within 60-30 min prior to incision. The administration of SAP before surgery has been specified in many clinical practice guidelines issued by professional societies or national authorities, such as those published by the ASHP-2013, Society for Healthcare Epidemiology of America (SHEA 2014), Infectious Diseases Society of America (IDSA 2014), recommend administration within 60 min before incision (120 min for vancomycin and fluoroquinolones due to prolonged infusion times). However, these recommendations are not based on systematic reviews of the literature and meta-analysis or a rigorous evaluation of the quality of the available evidence.
Mechanical bowel preparation and the use of oral antibiotics
WHO: The panel suggests that pre-operative oral antibiotics combined with mechanical bowel preparation (MBP) should be used to reduce the risk of SSI in adult patients undergoing elective colorectal surgery (Conditional recommendation, moderate-quality evidence). The panel recommends that MBP alone (without administration of oral antibiotics) should not be used for the purpose of reducing SSI in adult patients undergoing elective colorectal surgery (Strong recommendation, moderate quality evidence).
MBP is widely undertaken in the US but less so in the UK. The Cochrane collaboration suggests no bowel preparation is required before right-sided colectomy but may be required for the left haemicolectomy or distal resections, which matches current the practice in India. The panelists suggested that it is preferable to empty the large bowel to reduce the effect of anastomotic leak after surgery. Oral antibiotics were not recommended as more recent had shown no advantage study.,
Summary of the evidence
Twenty-four RCTs,,,,,,,,,,,,,,,,,,,,,,, were identified comparing either MBP with no MBP or the combined intervention of MBP and oral antibiotics with MBP and no oral antibiotics. Eleven RCTs,,,,,,,,,, including a total of 2416 MBP combined patients and comparing pre-operative with the administration of oral antibiotics compared with MBP and no oral antibiotics were identified. Moderate quality evidence showed that pre-operative MBP combined with oral antibiotics reduces the SSI rate when compared to MBP only. A total of 13 RCTs,,,,,,,,,,,, including a total of 4869 patients and comparing MBP with no MBP were identified. Moderate quality evidence shows that pre-operative MBP has neither benefit nor harm for the reduction of SSI rates when compared to no MBP at all. Of the 13 trials comparing MBP with no MBP, 3 reported specifically on SSI-attributable mortality,,, but they did not find any statistical difference in the mortality rate. Some observational studies,, using registry databases suggested that oral antibiotics may be effective in reducing the risk of SSI, irrespective of being combined with MBP. In addition, a prospective, randomised study strongly supports the use of oral antibiotics as part of a bundled intervention; however, in combination with MBP. SHEA/IDSA 2014 recommend to use MBP for colorectal procedures, but only combined with oral antibiotics. However, these recommendations are not based on systematic reviews of the literature and meta-analysis or a rigorous evaluation of the quality of the available evidence.
The WHO 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 pre-operatively or in the operating room (OR) (Strong recommendation, moderate quality of evidence).
The Indian group of panelists agreed unanimously without any deliberation for this recommendation.
Summary of the evidence
A total of 15 RCTs or quasi-randomised trials,,,,,,,,,,,,,, comparing the effect of pre-operative hair removal compared with no hair removal or different methods of hair removal (shaving, clipping and depilatory cream) were identified. In meta-analyses, no hair removal and clipping are similar regarding potential to cause microscopic skin trauma. A low to very low quality of evidence shows that shaving, clipping or the use of depilatory cream has neither benefit nor harm related to the reduction of the SSI rate when compared to no hair removal. However, when hair is removed, there is a low-quality of evidence showing that clipping has a significant benefit in reducing the SSI rate compared to shaving. When clipping and no hair removal were combined in the meta-analysis, a moderate quality of evidence showed that both are associated with a significantly lower risk of SSI when compared to shaving. A moderate quality of evidence shows that hair removal the day before surgery does not affect the SSI rate compared to hair removal on the day of surgery.
Surgical site preparation
WHO: The panel recommends alcohol-based antiseptic solutions based on CHG for surgical site skin preparation in patients undergoing surgical procedures (Strong recommendation, low-to-moderate quality of evidence).
The use of CHG aqueous followed by alcoholic CHG was recommended by the panelist. Initially, Povidone Iodine (PVP-I), then aqueous CHG and now alcoholic CHG is usually used in India according to the panelists. Alcohol-based solutions should be allowed to dry. The evidence is only moderate and subjective for alcoholic CHG use and should be used with caution in pediatric procedures and in vaginal mucosa. Panelists deliberated the use of CHG for vaginal prep. Vaginal epithelium has no mucus glands and keratin, therefore, is more prone to irritation with antiseptic use. Alcohol-based solutions carry the chance of electrosurgical burns if not allowed to dry completely which may be difficult because of vaginal pooling. OBGYN literature data suggest the concentration of CHG to be the main irritant. About 1%—2% solutions of CHG better tolerated in obstetric cases. Four per cent solution is well tolerated in non-pregnant cases for single applications. CHG is a better choice than PVP-I. Because of rapid onset and persistent antimicrobial activity.
Summary of evidence
17 RCTs,,,,,,,,,,,,,,,, comparing antiseptic agents (PVP-I and CHG) in aqueous or alcohol-based solutions were identified.
The following comparisons were evaluated in the selected studies:
- Alcohol-based antiseptic solutions compared with aqueous solutions
- CHG in an alcohol-based solution compared with PVP-I in an aqueous solution b) PVP-I in an alcohol-based solution compared with PVP-I in an aqueous solution
CHG compared with PVP-I-both in alcohol-based solutions Moderate-quality evidence shows that alcohol-based antiseptic solutions are overall more effective compared to aqueous solutions in reducing the risk of SSI. More specifically, a low quality of evidence shows a significant reduction of the SSI risk with the use of alcohol-based CHG compared to PVP-I in alcohol-based solutions. Moderate quality evidence shows also a significant benefit in using CHG alcohol-based solutions compared to aqueous PVP-I for the reduction of SSI rates. However, very low-quality evidence suggests that there is no significant difference between PVP-I alcohol-based solutions and PVP-I aqueous solutions. Several guidelines, such as those published by SHEA/IDSA 2014, NICE 2008 and 2013, recommend the use of an alcohol-based solution for surgical site preparation. However, these recommendations are not based on systematic reviews of the literature and meta-analysis or a rigorous evaluation of the quality of the available evidence.
Surgical hand preparation
WHO: The panel recommends that surgical hand preparation be performed either by scrubbing with a suitable antimicrobial soap and water or using a suitable ABHR before donning sterile gloves (Strong recommendation, moderate quality of evidence).
The Indian group of panelists agreed that the evidence is weak on alcohol-based hand scrub. Ambiguity exists about 'time to scrub', cleaning of nails, how to clean and how long to clean and subsequent gloving. The WHO guidelines on hand hygiene in health care is to be followed. Using the closed gloving technique, by a nurse gloving assistant, was considered to be appropriate. The use of liquid soap for scrubbing is encouraged.
Summary of evidence
Only six studies comprising 3 RCTs,, and three observational studies,, were identified with SSI as the primary outcome. All studies compared hand rubbing to hand scrubbing for surgical hand preparation. Hand rubbing was performed using either Sterilium®, the WHO recommended formulation II, Avagard® or Purell®. Hand scrubbing products contained either CHG or PVP-I and/or plain soap. Five studies compared ABHR to hand scrubbing with an antimicrobial soap containing either PVP-I 4% or CHG 4% and showed no significant difference in SSI. The same result was found in a cluster randomised cross-over trial comparing ABHR to hand scrubbing with plain soap. Evidence from RCTs with only a SSI outcome was considered for the development of the recommendation, which is rated as moderate due to inconsistency. The overall evidence shows that no difference between hand rubbing and hand scrubbing in reducing SSI.
| Pre-Operative And/or Intraoperative Measures|| |
Use of protocols for intensive perioperative blood glucose control
WHO: 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 (Conditional recommendation, low quality of evidence).
The Indian group of panelists recommended perioperative blood glucose levels be maintained at <200 mg/dL. An HBA1c of 7%—8% or less was agreed on as being optimal although evidence remains inadequate. The stricter maintenance of blood glucose lacks evidence in its effect of prevention of SSI. It was observed that in cardiac surgery, insulin is usually administered to achieve optimal perioperative glucose levels. The available evidence does not allow the definition of an optimal target level of blood glucose level.
Summary of evidence
Fifteen RCTs,,,,,,,,,,,,,, including a total of 2836 patients and comparing intensive perioperative blood glucose protocols compared with conventional protocols with less stringent blood glucose target levels were identified. Eight studies were performed in adult patients undergoing cardiac surgery,,,,,,,,, in patients undergoing abdominal or major noncardiac surgery,,,,,, and one other study in patients undergoing emergency cerebral aneurysm clipping. No study was available in a paediatric population. In two studies,, glucose control was performed intraoperatively only. Eight studies,,,,,,, investigated intra-and post-operative glucose control and five studies,,,, focused on post-operative glucose control. None of the studies had SSI as their primary outcome. Overall, there is low-quality evidence that a protocol with more strict blood glucose target levels has a significant benefit in reducing SSI rates when compared to a conventional protocol. Overall, there is an increased risk for hypoglycemic events with the use of either intensive protocol for blood glucose control.
Incisional wound irrigation
WHO: The panel considers that there is insufficient evidence to recommend for or against saline irrigation of incisional wounds before closure for 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 before closure should not be used for the purpose of preventing SSI (Conditional recommendations/low quality of evidence).
The Indian panelists deliberated the usefulness of incisional (saline) wound irrigation. Few of them believed wound irrigation does not reduce the risk of SSI. They were also of the view that if irrigation were undertaken then antiseptics should be encouraged and not antibiotics. For wound reexploration irrigation with PVP-I or/and CHG could be used. However, in case of irrigation/removal of debris, use of vancomycin was suggested but certainly not universally agreed. One of the panelists shared that they had used antibiotic bone cement but with no clear benefit.
Summary of evidence
The available evidence from 7 RCTs,,,,,, (10 estimates) showed that irrigation of the incisional wound with an aqueous PVP-I solution was beneficial in reducing the risk of SSI when compared to irrigation with a saline solution. Stratification of the evidence by contamination showed that the effect was attributable to incisional wound irrigation in clean and clean-contaminated procedures rated as wound Classes I and II according to the CDC system. The available evidence from five RCTs shows that the antibiotic irrigation of the incisional wound has neither benefit nor harm in reducing SSI when compared to no or saline solution irrigation.
WHO: 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 recommendation, moderate quality of evidence).
The Indian panelists deliberated on the difference between applying antiseptics to the wound and the use of triclosan-coated/impregnated sutures. Formation and subsequent consequences of bio-film around suture material were discussed in conjunction of use if triclosan-coated suture and its benefits were evaluated. There was affirmation of use and requirement of triclosan-coated/impregnated sutures in Indian healthcare o however concerns over AMR was shared, although poorly justified.
Summary of evidence
Eighteen studies (13 RCTs) and five cohort studies including a total of 7458 patients (RCTs, 5346; observational studies, 2112) and comparing the use of antimicrobial with non-coated sutures were identified. Included studies were performed in high-and middle-income countries. Types of surgical procedures included were colorectal, abdominal, breast, head and neck, lower limb, spinal, cardiac, vascular and other surgery. The types of sutures investigated in the included studies were triclosan-coated polydioxanone suture versus polydioxanone suture featuring a monofilament suture construction (3 RCTs,,); triclosan-coated polyglactin 910 suture versus. polyglactin 910 suture featuring a braided (multifilament) suture construction (7 RCTs,,,,,, and 4 observational studies,,,); and polyglactin 910 and poliglecaprone 25 (both triclosan-coated) sutures versus polyglactin 910 and poliglecaprone 25 sutures featuring a braided (polyglactin 910) and a monofilament (poliglecaprone 25) suture construction (3RCTs,, and one observational study. No adverse events have been associated in the included studies with the use of antimicrobial-coated sutures.,,,, However, evidence pointed out that there is limited evidence that triclosan may have negative effects on wound healing or lead to contact allergy. Although the development of resistance is mentioned as a concern, the daily absorption of triclosan from consumer products (for example, commercially-available hand soap) is higher than a single triclosan suture.,, Overall, there is moderate-to-low quality evidence that antimicrobial-coated sutures have significant benefit in reducing SSI rates in patients undergoing surgical procedures when compared to non-coated sutures. Per these analyses, the effect seems to be independent of the type of suture, procedure or wound contamination classification.
| Post-Operative Measures|| |
Surgical antibiotic prophylaxis prolongation
WHO: The panel recommends against the prolongation of SAP administration after completion of the operation for the purpose of preventing SSI (Strong recommendation/moderate quality of evidence).
The Indian panel deliberated on this and reached a consensus to not abuse antibiotic use. They believed a surgeon should judiciously administer antibiotic after considering patient characteristics, type of surgery and other risks for infection. For example, it was considered to be advisable to prolong SAP administration in a diabetic patient with implant and/or drain or cardiac valve.
Summary of evidence
No recommendation could be concluded on the benefit or harm of this approach. For cardiac (2 RCTs), and orthognathic surgery (3 RCTs),,, there was some evidence that prolonging antibiotic administration after completion of the operation may be beneficial in reducing the risk of SSI when compared to single-dose prophylaxis. By contrast, other RCTs,,,,,, showed no benefit of prolonging antibiotic prophylaxis beyond 24 h compared to prophylaxis for up to 24 h in these types of surgery. In vascular surgery, there was some evidence from one RCT that prolonging antibiotic prophylaxis until intravenous lines and tubes are removed may be beneficial in reducing the risk of SSI when compared to single-dose prophylaxis.
Antimicrobial prophylaxis in the presence of a drain and optimal timing for wound drain removal
WHO: The panel suggests that perioperative antibiotic prophylaxis should not be continued to the presence of a wound drain for the purpose of preventing SSI (Conditional recommendation, low quality of evidence). The panel suggests removing the wound drain when clinically indicated. No evidence was found to recommend an optimal timing of wound drain removal for the purpose of preventing SSI (Conditional recommendation, very low quality of evidence).
The Indian panelists deliberated and accepted the above WHO recommendation. They added that the use of antibiotics when a drain is present may be at discretion of surgeon on situational basis.
Summary of evidence
Seven RCTs,,,,,, were identified. They included a total of 1670 patients and investigated whether antibiotics should be administered pre-operatively as a single dose and possibly re-dosed according to the duration of the operation or if their administration should be extended to the post-operative period. Three studies reported a prolonged antibiotic administration until the wound drain was removed. In the remaining four trials, patients received a 3-day, or 5-day intravenous course. Patients enroled in the studies underwent general surgery,,, kidney transplantation and pilonidal sinus surgery. One trial determined whether prolonged antibiotic prophylaxis reduced the risk of infectious complications for patients undergoing elective thoracic surgery with tube thoracostomy. The antibiotic was continued for 48 h after the procedure or until all thoracostomy tubes were removed, whichever came first. There is low-quality evidence that prolonged antibiotic prophylaxis in the presence of a wound drain has neither benefit nor harm in reducing SSI when compared to perioperative prophylaxis alone. Nine studies investigated the duration of drains in patients undergoing mastectomy,,,,,,,, and two studies after hip or knee arthroplasty., One trial compared three different time points of drain removal (12 h, 24 h and 48 h). There is very low-quality evidence that the early removal of wound drains has neither benefit nor harm in reducing the SSI rate when compared to late removal.
Panelists also considered and evaluated other recommendations from the WHO guidelines. However, considering the diverse healthcare set up across India, those are not included in this framework. These guidelines are the must doable and most doable action items that HCP can practice to bring down the mortality and morbidity in patients due to SSI/HAI.
Grade categories for the quality of evidence
We are very confident that the true effect lies close to that of the estimate of the effect.
We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect; however, there is a possibility that it is substantially different.
Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.
We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of the effect. The strength of recommendations was rated as follows:
The panel was confident that the benefits of the intervention outweighed the risks.
The panel considered that the benefits of the intervention probably outweighed the risks.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
WHO document on Global Guidelines For the Prevention of Surgical Site Infection. WHO Guidelines Development Group; Geneva, Switzerland; 2016;58-177.
Kamat US, Fereirra AM, Kulkarni MS, Motghare DD. A prospective study of surgical site infections in a teaching hospital in Goa. Indian J Surg 2008;70:120-4.
Bhatia JY, Pandey K, Rodrigues C, Mehta A, Joshi VR. Postoperative wound infection in patients undergoing coronary artery bypass graft surgery: A prospective study with evaluation of risk factors. Indian J Med Microbiol 2003;21:246-51.
] [Full text]
Pawar M, Mehta Y, Ansari A, Nair R, Trehan N. Nosocomial infections and balloon counterpulsation: Risk factors and outcome. Asian Cardiovasc Thorac Ann 2005;13:316-20.
Murthy R, Sengupta S, Maya N, Shivananda PG. Incidence of post operative wound infection and their antibiogram in a teaching and referral hospital. Indian J Med Sci 1998;52:553-5.
Suchitra JB, Lakshmidevi N. Surgical site infections: Assessing risk factors, outcomes and antimicriobial sensitivity patterns. Afr J Microbiol Res 2009b; 3:175-9.
Agarwal M, Thomas P. Prevalence of post-op. Nosocomial infection in neurosurgical patients and associated risk factors — A prospective study of 2441 patients. Nurs J India 2003;94:197-8, 212.
Ashraf M, Biswas J, Gupta S, Alam N. Determinants of wound infections for breast procedures: Assessment of the risk of wound infection posed by an invasive procedure for subsequent operation. Int J Surg 2009;7:543-6.
Kamat U, Ferreira A, Savio R, Motghare D. Antimicrobial resistance among nosocomial isolates in a teaching hospital in Goa. Indian J Community Med 2008;33:89-92.
] [Full text]
Lilani SP, Jangale N, Chowdhary A, Daver GB. Surgical site infection in clean and clean-contaminated cases. J Med Microbiol 2005;23:249-52.
Shindholimath VV, Seenu V, Parshad R, Chaudhry R, Kumar A. Factors influencing wound infection following laparoscopic cholecystectomy. Trop Gastroenterol 2003;24:90-2.
Suchitra JB, Lakshmidevi N. Hospital-acquired infections: Are prevention strategies matching incidence rates? Healthc Infect 2009a; 14:21-5.
Kownhar H, Shankar EM, Vignesh R, Sekar R, Velu V, Rao UA. High isolation rate of Staphylococcus aureus
from surgical site infections in an Indian hospital. J Antimicrob Chemother 2008;61:758-60.
Arora A, Bharadwaj P, Chaturvedi H, Chowbey P, Gupta S, Leaper D, et al
. Deliberation from Ethicon Panelists for Drafting Clinical Practice Guidelines for Surgical Site Infections (SSIs) Prevention in line with Global Guidelines. World Health Organization, Delhi, 2017.
Byrne DJ, Napier A, Cuschieri A. Prevention of postoperative wound infection in clean and potentially contaminated surgery. A prospective, randomised, double-blind, placebo-controlled clinical trial. Surg Res Commun 1992;12:43-52.
Lynch W, Davey PG, Malek M, Byrne DJ, Napier A. Cost-effectiveness analysis of the use of chlorhexidine detergent in preoperative whole-body disinfection in wound infection prophylaxis. J Hosp Infect 1992;21:179-91.
Rotter ML. A placebo-controlled trial of the effect of two preoperative baths or showers with chlorhexidine detergent on postoperative wound infection rates. J Hosp Infect 1988;12:137-8.
Earnshaw JJ, Berridge DC, Slack RC, Makin GS, Hopkinson BR. Do preoperative chlorhexidine baths reduce the risk of infection after vascular reconstruction? Eur J Vasc Surg 1989;3:323-6.
Hayek LJ, Emerson JM. Preoperative whole body disinfection — A controlled clinical study. J Hosp Infect 1988;11 Suppl B: 15-9.
Randall PE, Ganguli LA, Keaney MG, Marcuson RW. Prevention of wound infection following vasectomy. Br J Urol 1985;57:227-9.
Veiga DF, Damasceno CA, Veiga-Filho J, Figueiras RG, Vieira RB, Garcia ES, et al
. Randomized controlled trial of the effectiveness of chlorhexidine showers before elective plastic surgical procedures. Infect Control Hosp Epidemiol 2009;30:77-9.
Ayliffe GA, Noy MF, Babb JR, Davies JG, Jackson J. A comparison of pre-operative bathing with chlorhexidine-detergent and non-medicated soap in the prevention of wound infection. J Hosp Infect 1983;4:237-44.
Leigh DA, Stronge JL, Marriner J, Sedgwick J. Total body bathing with 'hibiscrub' (chlorhexidine) in surgical patients: A controlled trial. J Hosp Infect 1983;4:229-35.
Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP, et al
. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med 1992;326:281-6.
van Kasteren ME, Manniën J, Ott A, Kullberg BJ, de Boer AS, Gyssens IC, et al
. Antibiotic prophylaxis and the risk of surgical site infections following total hip arthroplasty: Timely administration is the most important factor. Clin Infect Dis 2007;44:921-7.
Weber WP, Marti WR, Zwahlen M, Misteli H, Rosenthal R, Reck S, et al
. The timing of surgical antimicrobial prophylaxis. Ann Surg 2008;247:918-26.
Steinberg JP, Braun BI, Hellinger WC, Kusek L, Bozikis MR, Bush AJ, et al
. Timing of antimicrobial prophylaxis and the risk of surgical site infections: Results from the trial to reduce antimicrobial prophylaxis errors. Ann Surg 2009;250:10-6.
Ho VP, Barie PS, Stein SL, Trencheva K, Milsom JW, Lee SW, et al
. Antibiotic regimen and the timing of prophylaxis are important for reducing surgical site infection after elective abdominal colorectal surgery. Surg Infect (Larchmt) 2011;12:255-60.
Koch CG, Nowicki ER, Rajeswaran J, Gordon SM, Sabik JF 3rd
, Blackstone EH, et al
. When the timing is right: Antibiotic timing and infection after cardiac surgery. J Thorac Cardiovasc Surg 2012;144:931-7.e4.
Koch CG, Li L, Hixson E, Tang A, Gordon S, Longworth D, et al
. Is it time to refine? An exploration and simulation of optimal antibiotic timing in general surgery. J Am Coll Surg 2013;217:628-35.
El-Mahallawy HA, Hassan SS, Khalifa HI, El-Sayed Safa MM, Khafagy MM. Comparing a combination of penicillin G and gentamicin to a combination of clindamycin and Amikacin as prophylactic antibiotic regimens in prevention of clean contaminated wound infections in cancer surgery. J Egypt Natl Canc Inst 2013;25:31-5.
Muñoz Platón E, Jiménez Antolín JA, Brea Zubigaray S, Bravo García P. [The effect of surgical antibiotic prophylaxis and the timing of its administration on the risk of surgical wound infection]. Rev Clin Esp 1995;195:669-73.
Lizán-García M, García-Caballero J, Asensio-Vegas A. Risk factors for surgical-wound infection in general surgery: A prospective study. Infect Control Hosp Epidemiol 1997;18:310-5.
Trick WE, Scheckler WE, Tokars JI, Jones KC, Reppen ML, Smith EM, et al
. Modifiable risk factors associated with deep sternal site infection after coronary artery bypass grafting. J Thorac Cardiovasc Surg 2000;119:108-14.
Garey KW, Dao T, Chen H, Amrutkar P, Kumar N, Reiter M, et al
. Timing of vancomycin prophylaxis for cardiac surgery patients and the risk of surgical site infections. J Antimicrob Chemother 2006;58:645-50.
Kasatpibal N, Nørgaard M, Sørensen HT, Schønheyder HC, Jamulitrat S, Chongsuvivatwong V, et al
. Risk of surgical site infection and efficacy of antibiotic prophylaxis: A cohort study of appendectomy patients in Thailand. BMC Infect Dis 2006;6:111.
Espin-Basany E, Sanchez-Garcia JL, Lopez-Cano M, Lozoya-Trujillo R, Medarde-Ferrer M, Armadans-Gil L, et al
. Prospective, randomised study on antibiotic prophylaxis in colorectal surgery. Is it really necessary to use oral antibiotics? Int J Colorectal Dis 2005;20:542-6.
Lewis RT. Oral versus systemic antibiotic prophylaxis in elective colon surgery: A randomized study and meta-analysis send a message from the 1990s. Can J Surg 2002;45:173-80.
Oshima T, Takesue Y, Ikeuchi H, Matsuoka H, Nakajima K, Uchino M, et al
. Preoperative oral antibiotics and intravenous antimicrobial prophylaxis reduce the incidence of surgical site infections in patients with ulcerative colitis undergoing IPAA. Dis Colon Rectum 2013;56:1149-55.
Sadahiro S, Suzuki T, Tanaka A, Okada K, Kamata H, Ozaki T, et al
. Comparison between oral antibiotics and probiotics as bowel preparation for elective colon cancer surgery to prevent infection: Prospective randomized trial. Surgery 2014;155:493-503.
Takesue Y, Yokoyama T, Akagi S, Ohge H, Murakami Y, Sakashita Y, et al
. A brief course of colon preparation with oral antibiotics. Surg Today 2000;30:112-6.
Ishida H, Yokoyama M, Nakada H, Inokuma S, Hashimoto D. Impact of oral antimicrobial prophylaxis on surgical site infection and methicillin-resistant Staphylococcus aureus
infection after elective colorectal surgery. Results of a prospective randomized trial. Surg Today 2001;31:979-83.
Kobayashi M, Mohri Y, Tonouchi H, Miki C, Nakai K, Kusunoki M, et al
. Randomized clinical trial comparing intravenous antimicrobial prophylaxis alone with oral and intravenous antimicrobial prophylaxis for the prevention of a surgical site infection in colorectal cancer surgery. Surg Today 2007;37:383-8.
Stellato TA, Danziger LH, Gordon N, Hau T, Hull CC, Zollinger RM Jr., et al
. Antibiotics in elective colon surgery. A randomized trial of oral, systemic, and oral/systemic antibiotics for prophylaxis. Am Surg 1990;56:251-4.
Horie T. Randomized controlled trial on the necessity of chemical cleaning as preoperative preparation for colorectal cancer surgery. Dokkyo J Med Sci 2007;34:205-12.
Roos D, Dijksman LM, Oudemans-van Straaten HM, de Wit LT, Gouma DJ, Gerhards MF. Randomized clinical trial of perioperative elective decontamination of the digestive tract versus placebo in elective gastrointestinal surgery. Br J Surg 2011;98:1365-72.
Taylor EW, Lindsay G. Selective decontamination of the colon before elective colorectal surgery. West of Scotland surgical infection study group. World J Surg 1994;18:926-31.
Barrera EA, Cid BH, Bannura CG, Contreras RJ, Zniga TC, Mansilla EJ. Usefulness of anterograde mechanical bowel cleansing in colorectal surgery. Rev Child Cir 2012;64:373-7.
Bretagnol F, Panis Y, Rullier E, Rouanet P, Berdah S, Dousset B, et al
. Rectal cancer surgery with or without bowel preparation: The french GRECCAR III multicenter single-blinded randomized trial. Ann Surg 2010;252:863-8.
Bucher P, Gervaz P, Soravia C, Mermillod B, Erne M, Morel P. Randomized clinical trial of mechanical bowel preparation versus no preparation before elective left-sided colorectal surgery. Br J Surg 2005;92:409-14.
Burke P, Mealy K, Gillen P, Joyce W, Traynor O, Hyland J, et al
. Requirement for bowel preparation in colorectal surgery. Br J Surg 1994;81:907-10.
Contant CM, Hop WC, van't Sant HP, Oostvogel HJ, Smeets HJ, Stassen LP, et al
. Mechanical bowel preparation for elective colorectal surgery: A multicentre randomised trial. Lancet 2007;370:2112-7.
Fa-Si-Oen P, Roumen R, Buitenweg J, van de Velde C, van Geldere D, Putter H, et al
. Mechanical bowel preparation or not? Outcome of a multicenter, randomized trial in elective open colon surgery. Dis Colon Rectum 2005;48:1509-16.
Jung B, Påhlman L, Nyström PO, Nilsson E; Mechanical Bowel Preparation Study Group. Multicentre randomized clinical trial of mechanical bowel preparation in elective colonic resection. Br J Surg 2007;94:689-95.
Miettinen RP, Laitinen ST, Mäkelä JT, Pääkkönen ME. Bowel preparation with oral polyethylene glycol electrolyte solution vs. no preparation in elective open colorectal surgery: Prospective, randomized study. Dis Colon Rectum 2000;43:669-75.
Pena-Soria MJ, Mayol JM, Anula R, Arbeo-Escolar A, Fernandez-Represa JA. Single-blinded randomized trial of mechanical bowel preparation for colon surgery with primary intraperitoneal anastomosis. J Gastrointest Surg 2008;12:2103-8.
Ram E, Sherman Y, Weil R, Vishne T, Kravarusic D, Dreznik Z, et al
. Is mechanical bowel preparation mandatory for elective colon surgery? A prospective randomized study. Arch Surg 2005;140:285-8.
Santos JC Jr., Batista J, Sirimarco MT, Guimaraes AS, Levy CE. Prospective randomized trial of mechanical bowel preparation in patients undergoing elective colorectal surgery. Br J Surg 1994;81:1673-6.
Young Tabusso F, Celis Zapata J, Berrospi Espinoza F, Payet Meza E, Ruiz Figueroa E. Mechanical preparation in elective colorectal surgery, a usual practice or a necessity?. Rev Gastroenterol Peru 2002;22:152-8.
Zmora O, Mahajna A, Bar-Zakai B, Rosin D, Hershko D, Shabtai M, et al
. Colon and rectal surgery without mechanical bowel preparation: A randomized prospective trial. Ann Surg 2003;237:363-7.
Cannon JA, Altom LK, Deierhoi RJ, Morris M, Richman JS, Vick CC, et al
. Preoperative oral antibiotics reduce surgical site infection following elective colorectal resections. Dis Colon Rectum 2012;55:1160-6.
Morris MS, Graham LA, Chu DI, Cannon JA, Hawn MT. Oral antibiotic bowel preparation significantly reduces surgical site infection rates and readmission rates in elective colorectal surgery. Ann Surg 2015;261:1034-40.
Scarborough JE, Mantyh CR, Sun Z, Migaly J. Combined mechanical and oral antibiotic bowel preparation reduces incisional surgical site infection and anastomotic leak rates after elective colorectal resection: An analysis of colectomy-targeted ACS NSQIP. Ann Surg 2015;262:331-7.
Anthony T, Murray BW, Sum-Ping JT, Lenkovsky F, Vornik VD, Parker BJ, et al
. Evaluating an evidence-based bundle for preventing surgical site infection: A randomized trial. Arch Surg 2011;146:263-9.
Alexander JW, Fischer JE, Boyajian M, Palmquist J, Morris MJ. The influence of hair-removal methods in wound infections. Arch Surg 1983;118:347-52.
Thur de Koos P, McComas B. Shaving versus skin depilatory cream for preoperative skin preparation. A prospective study of wound infection rates. Am J Surg 1983;145:377-8.
Goëau-Brissonnière O, Coignard S, Meråo AP, Haicault G, Sasako M, Patel JC, et al
. Preoperative skin preparation. A prospective study comparing a depilatory agent in shaving. Presse Med 1987;16:1517-9.
Abouzari M, Sodagari N, Hasibi M, Behzadi M, Rashidi A. Re: Nonshaved cranial surgery in black africans: A short-term prospective preliminary study (Adeleye and olowookere, surg neurol 2008;69-72) effect of hair on surgical wound infection after cranial surgery: A 3-armed randomized clinical trial. Surg Neurol 2009;71:261-2.
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;5:717-22.
Balthazar ER, Colt JD, Nichols RL. Preoperative hair removal: A random prospective study of shaving versus clipping. South Med J 1982;75:799-801.
Celik SE, Kara A. Does shaving the incision site increase the infection rate after spinal surgery? Spine 2007;32:1575-7.
Court-Brown CM. Preoperative skin depilation and its effect on postoperative wound infections. J R Coll Surg Edinb 1981;26:238-41.
Grober ED, Domes T, Fanipour M, Copp JE. Preoperative hair removal on the male genitalia: Clippers vs. razors. J Sex Med 2013;10:589-94.
Horgan MA, Kernan JC, Schwartz MS, Kellogg JX, McMenomey SO, Delashaw JB, et al
. Shaveless brain surgery: Safe, well tolerated, and cost effective. Skull Base Surg 1999;9:253-8.
Ilankovan V, Starr DG. Preoperative shaving: Patient and surgeon preferences and complications for the Gillies incision. J R Coll Surg Edinb 1992;37:399-401.
Kattipattanapong W, Isaradisaikul S, Hanprasertpong C. Surgical site infections in ear surgery: Hair removal effect; a preliminary, randomized trial study. Otolaryngol Head Neck Surg 2013;148:469-74.
Powis SJ, Waterworth TA, Arkell DG. Preoperative skin preparation: Clinical evaluation of depilatory cream. Br Med J 1976;2:1166-8.
Rojanapirom S, Danchaivijitr S. Pre-operative shaving and wound infection in appendectomy. J Med Assoc Thai 1992;75 Suppl 2:20-3.
Seropian R, Reynolds BM. Wound infections after preoperative depilatory versus razor preparation. Am J Surg 1971;121:251-4.
Segal CG, Anderson JJ. Preoperative skin preparation of cardiac patients. AORN J 2002;76:821-8.
Rodrigues AL, Simões Mde L. Incidence of surgical site infection with pre-operative skin preparation using 10% polyvidone-iodine and 0.5% chlorhexidine-alcohol. Rev Col Bras Cir 2013;40:443-8.
Sistla SC, Prabhu G, Sistla S, Sadasivan J. Minimizing wound contamination in a 'clean' surgery: Comparison of chlorhexidine-ethanol and povidone-iodine. Chemotherapy 2010;56:261-7.
Srinivas A, Kaman L, Raj P, Gautam V, Dahiya D, Singh G, et al
. Comparison of the efficacy of chlorhexidine gluconate versus povidone iodine as preoperative skin preparation for the prevention of surgical site infections in clean-contaminated upper abdominal surgeries. Surg Today 2014;45:1378-84.
Paocharoen V, Mingmalairak C, Apisarnthanarak A. Comparison of surgical wound infection after preoperative skin preparation with 4% chlohexidine and povidone iodine: A prospective randomized trial. J Med Associ Thai 2009;92:898-902.
Bibbo C, Patel DV, Gehrmann RM, Lin SS. Chlorhexidine provides superior skin decontamination in foot and ankle surgery: A prospective randomized study. Clin Orthop Relat Res 2005;438:204-8.
Saltzman MD, Nuber GW, Gryzlo SM, Marecek GS, Koh JL. Efficacy of surgical preparation solutions in shoulder surgery. J Bone Joint Surg Am 2009;91:1949-53.
Roberts A, Wilcox K, Devineni R, Harris R, Osevala M. Skin preparation in CABG surgery: A prospective randomized trial. Complications Surg 1995;14:741-7.
Howard R. Comparison of a 10-minute aqueous iodophor and 2-minute water insoluble iodophor in alcohol preoperative skin preparation. Complications Surg 1991;10;43.
Hort KR, DeOrio JK. Residual bacterial contamination after surgical preparation of the foot or ankle with or without alcohol. Foot Ankle Int 2002;23:946-8.
Gilliam DL, Nelson CL. Comparison of a one-step iodophor skin preparation versus traditional preparation in total joint surgery. Clin Orthop Relat Res 1990;250:258-60.
Darouiche RO, Wall MJ Jr., Itani KM, Otterson MF, Webb AL, Carrick MM, et al
. Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. New Engl J Med 2010;362:18-26.
Savage JW, Weatherford BM, Sugrue PA, Nolden MT, Liu JC, Song JK, et al
. Efficacy of surgical preparation solutions in lumbar spine surgery. J Bone Joint Surg Am 2012;94:490-4.
Veiga DF, Damasceno CA, Veiga-Filho J, Figueiras RG, Vieira RB, Florenzano FH, et al
. Povidone iodine versus chlorhexidine in skin antisepsis before elective plastic surgery procedures: A randomized controlled trial. Plast Reconstr Surg 2008;122:170e-1e.
Cheng K, Robertson H, St Mart JP, Leanord A, McLeod I. Quantitative analysis of bacteria in forefoot surgery: A comparison of skin preparation techniques. Foot Ankle Int 2009;30:992-7.
Berry AR, Watt B, Goldacre MJ, Thomson JW, McNair TJ. A comparison of the use of povidone-iodine and chlorhexidine in the prophylaxis of postoperative wound infection. J Hosp Infect 1982;3:55-63.
Tuuli MG, Liu J, Stout MJ, Martin S, Cahill AG, Odibo AO, et al
. A randomized trial comparing skin antiseptic agents at cesarean delivery. N Engl J Med 2016;374:647-55.
Parienti JJ, Thibon P, Heller R, Le Roux Y, von Theobald P, Bensadoun H, et al
. Hand-rubbing with an aqueous alcoholic solution vs. traditional surgical hand-scrubbing and 30-day surgical site infection rates: A randomized equivalence study. JAMA 2002;288:722-7.
Nthumba PM, Stepita-Poenaru E, Poenaru D, Bird P, Allegranzi B, Pittet D, et al
. Cluster-randomized, crossover trial of the efficacy of plain soap and water versus alcohol-based rub for surgical hand preparation in a rural hospital in Kenya. Br J Surg 2010;97:1621-8.
Al-Naami MY, Anjum MN, Afzal MF, Al-Yami MS, Al-Qahtani SM, Al-Dohayan AD, et al
. Alcohol- based hand-rub versus traditional surgical scrub and the risk of surgical site infection: A randomized controlled equivalent trial. EWMA J 2009;9:5-10.
Weight CJ, Lee MC, Palmer JS. Avagard hand antisepsis vs. traditional scrub in 3600 pediatric urologic procedures. Urology 2010;76:15-7.
Marchand R, Theoret S, Dion D, Pellerin M. Clinical implementation of a scrubless chlorhexidine/ethanol pre-operative surgical handrub. Can Oper Room Nurs J 2008;26:21-2, 26, 29-31.
Adjoussou S, Konan Blé R, Séni K, Fanny M, Toure-Ecra A, Koffi A, et al
. Value of hand disinfection by rubbing with alcohol prior to surgery in a tropical setting. Med Trop (Mars) 2009;69:463-6.
Emam IA, Allan A, Eskander K, Dhanraj K, Farag el-S, El-Kadi Y, et al
. Our experience of controlling diabetes in the peri-operative period of patients who underwent cardiac surgery. Diabetes Res Clin Pract 2010;88:242-6.
Kirdemir P, Yildirim V, Kiris I, Gulmen S, Kuralay E, Ibrisim E, et al
. Does continuous insulin therapy reduce postoperative supraventricular tachycardia incidence after coronary artery bypass operations in diabetic patients? J Cardiothorac Vasc Anesth 2008;22:383-7.
Yuan J, Liu T, Zhang X, Si Y, Ye Y, Zhao C, et al
. Intensive versus conventional glycemic control in patients with diabetes during enteral nutrition after gastrectomy. J Gastrointest Surg 2015;19:1553-8.
Albacker T, Carvalho G, Schricker T, Lachapelle K. High-dose insulin therapy attenuates systemic inflammatory response in coronary artery bypass grafting patients. Ann Thorac Surg 2008;86:20-7.
Cao SG, Ren JA, Shen B, Chen D, Zhou YB, Li JS, et al
. Intensive versus conventional insulin therapy in type 2 diabetes patients undergoing D2 gastrectomy for gastric cancer: A randomized controlled trial. World J Surg 2011;35:85-92.
Lazar HL, McDonnell MM, Chipkin S, Fitzgerald C, Bliss C, Cabral H, et al
. Effects of aggressive versus moderate glycemic control on clinical outcomes in diabetic coronary artery bypass graft patients. Ann Surg 2011;254:458-63.
Abdelmalak BB, Bonilla A, Mascha EJ, Maheshwari A, Tang WH, You J, et al
. Dexamethasone, light anaesthesia, and tight glucose control (DeLiT) randomized controlled trial. Br J Anaesth 2013;111:209-21.
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 neuro Intensive Care Unit after intracranial aneurysm clipping in patients with acute subarachnoid hemorrhage: A randomized prospective pilot trial. J Neurosurg Anesthesiol 2007;19:156-60.
Chan RP, Galas FR, Hajjar LA, Bello CN, Piccioni MA, Auler JO Jr. Intensive perioperative glucose control does not improve outcomes of patients submitted to open-heart surgery: A randomized controlled trial. Clinics (Sao Paulo) 2009;64:51-60.
Desai SP, Henry LL, Holmes SD, Hunt SL, Martin CT, Hebsur S, et al
. Strict versus liberal target range for perioperative glucose in patients undergoing coronary artery bypass grafting: A prospective randomized controlled trial. J Thorac Cardiovasc Surg 2012;143:318-25.
Gandhi GY, Nuttall GA, Abel MD, Mullany CJ, Schaff HV, O'Brien PC, et al
. Intensive intraoperative insulin therapy versus conventional glucose management during cardiac surgery: A randomized trial. Ann Intern Med 2007;146:233-43.
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.
Okabayashi T, Shima Y, Sumiyoshi T, Kozuki A, Tokumaru T, Iiyama T, et al
. Intensive versus intermediate glucose control in surgical Intensive Care Unit patients. Diabetes Care 2014;37:1516-24.
Cao S, Zhou Y, Chen D, Niu Z, Wang D, Lv L, et al
. Intensive versus conventional insulin therapy in nondiabetic patients receiving parenteral nutrition after D2 gastrectomy for gastric cancer: A randomized controlled trial. J Gastrointest Surg 2011;15:1961-8.
Zheng R, Gu C, Wang Y, Yang Z, Dou K, Wang J, et al
. Impacts of intensive insulin therapy in patients undergoing heart valve replacement. Heart Surg Forum 2010;13:E292-8.
Cheng MT, Chang MC, Wang ST, Yu WK, Liu CL, Chen TH, et al
. Efficacy of dilute betadine solution irrigation in the prevention of postoperative infection of spinal surgery. Spine (Phila Pa 1976) 2005;30:1689-93.
Chang FY, Chang MC, Wang ST, Yu WK, Liu CL, Chen TH, et al
. Can povidone-iodine solution be used safely in a spinal surgery? Eur Spine J 2006;15:1005-14.
Kokavec M, Frist Ãakovãa M. Efficacy of antiseptics in the prevention of post-operative infections of the proximal femur, hip and pelvis regions in orthopedic pediatric patients. Analysis of the first results. Acta Chir Orthop Traumatol Cech 2008;75:106-9.
Rogers DM, Blouin GS, O'Leary JP. Povidone-iodine wound irrigation and wound sepsis. Surg Gynecol Obstet 1983;157:426-30.
Sindelar WF, Brower ST, Merkel AB, Takesue EI. Randomised trial of intraperitoneal irrigation with low molecular weight povidone-iodine solution to reduce intra-abdominal infectious complications. J Hosp Infect 1985;6 Suppl A: 103-14.
Sindelar WF, Mason GR. Irrigation of subcutaneous tissue with povidone-iodine solution for prevention of surgical wound infections. Surg Gynecol Obstet 1979;148:227-31.
Lau WY, Fan ST, Chu KW, Yip WC, Chong KK, Wong KK, et al
. Combined topical povidone-iodine and systemic antibiotics in postappendicectomy wound sepsis. Br J Surg 1986;73:958-60.
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;27:97-132.
Baracs J, Huszár O, Sajjadi SG, Horváth OP. Surgical site infections after abdominal closure in colorectal surgery using triclosan-coated absorbable suture (PDS plus) vs. uncoated sutures (PDS II): A randomized multicenter study. Surg Infect (Larchmt) 2011;12:483-9.
Diener MK, Knebel P, Kieser M, Schüler P, Schiergens TS, Atanassov V, et al
. Effectiveness of triclosan-coated PDS plus versus uncoated PDS II sutures for prevention of surgical site infection after abdominal wall closure: The randomised controlled PROUD trial. Lancet 2014;384:142-52.
Justinger C, Slotta JE, Ningel S, Gräber S, Kollmar O, Schilling MK, et al
. Surgical-site infection after abdominal wall closure with triclosan-impregnated polydioxanone sutures: Results of a randomized clinical pathway facilitated trial (NCT00998907). Surgery 2013;154:589-95.
Ford HR, Jones P, Gaines B, Reblock K, Simpkins DL. Intraoperative handling and wound healing: Controlled clinical trial comparing coated VICRYL plus antibacteriasl suture (coated polyglactin 910 suture with triclosan) with coated VICRYL suture (coated polyglactin 910 suture). Surg Infect (Larchmt) 2005;6:313-21.
Galal I, El-Hindawy K. Impact of using triclosan-antibacterial sutures on incidence of surgical site infection. Am J Surg 2011;202:133-8.
Isik I, Selimen D, Senay S, Alhan C. Efficiency of antibacterial suture material in cardiac surgery: A double-blind randomized prospective study. Heart Surg Forum 2012;15:E40-5.
Mingmalairak C, Ungbhakorn P, Paocharoen V. Efficacy of antimicrobial coating suture coated polyglactin 910 with tricosan (Vicryl plus) compared with polyglactin 910 (Vicryl) in reduced surgical site infection of appendicitis, double blind randomized control trial, preliminary safety report. J Med Assoc Thai 2009;92:770-5.
Nakamura T, Kashimura N, Noji T, Suzuki O, Ambo Y, Nakamura F, et al
. Triclosan-coated sutures reduce the incidence of wound infections and the costs after colorectal surgery: A randomized controlled trial. Surgery 2013;153:576-83.
Rasić Z, Schwarz D, Adam VN, Sever M, Lojo N, Rasić D, et al
. Efficacy of antimicrobial triclosan-coated polyglactin 910 (Vicryl* plus) suture for closure of the abdominal wall after colorectal surgery. Coll Antropol 2011;35:439-43.
Seim BE, Tønnessen T, Woldbaek PR. Triclosan-coated sutures do not reduce leg wound infections after coronary artery bypass grafting. Interact Cardiovasc Thorac Surg 2012;15:411-5.
Chen SY, Chen TM, Dai NT, Fu JP, Chang SC, Deng SC, et al
. Do antibacterial-coated sutures reduce wound infection in head and neck cancer reconstruction? Eur J Surg Oncol 2011;37:300-4.
Hoshino S, Yoshida Y, Tanimura S, Yamauchi Y, Noritomi T, Yamashita Y, et al
. A study of the efficacy of antibacterial sutures for surgical site infection: A retrospective controlled trial. Int Surg 2013;98:129-32.
Okada N, Nakamura T, Ambo Y, Takada M, Nakamura F, Kishida A, et al
. Triclosan-coated abdominal closure sutures reduce the incidence of surgical site infections after pancreaticoduodenectomy. Surg Infect (Larchmt) 2014;15:305-9.
Ueno M, Saito W, Yamagata M, Imura T, Inoue G, Nakazawa T, et al
. Triclosan-coated sutures reduce wound infections after spinal surgery: A retrospective, nonrandomized, clinical study. Spine J 2015;15:933-8.
Thimour-Bergström L, Roman-Emanuel C, Scherstén H, Friberg Ö, Gudbjartsson T, Jeppsson A, et al
. Triclosan-coated sutures reduce surgical site infection after open vein harvesting in coronary artery bypass grafting patients: A randomized controlled trial. Eur J Cardiothorac Surg 2013;44:931-8.
Turtiainen J, Saimanen EI, Mäkinen KT, Nykänen AI, Venermo MA, Uurto IT, et al
. Effect of triclosan-coated sutures on the incidence of surgical wound infection after lower limb revascularization surgery: A randomized controlled trial. World J Surg 2012;36:2528-34.
Williams N, Sweetland H, Goyal S, Ivins N, Leaper DJ. Randomized trial of antimicrobial-coated sutures to prevent surgical site infection after breast cancer surgery. Surg Infect (Larchmt) 2011;12:469-74.
Laas E, Poilroux C, Bézu C, Coutant C, Uzan S, Rouzier R, et al
. Antibacterial-coated suture in reducing surgical site infection in breast surgery: A prospective study. Int J Breast Cancer 2012;2012:819578.
Deliaert AE, Van den Kerckhove E, Tuinder S, Fieuws S, Sawor JH, Meesters-Caberg MA, et al
. The effect of triclosan-coated sutures in wound healing. A double blind randomised prospective pilot study. J Plast Reconstr Aesthet Surg 2009;62:771-3.
Bhutani T, Jacob SE. Triclosan: A potential allergen in suture-line allergic contact dermatitis. Dermatol Surg 2009;35:888-9.
Barbolt TA. Chemistry and safety of triclosan, and its use as an antimicrobial coating on coated VICRYL* plus antibacterial suture (coated polyglactin 910 suture with triclosan). Surg Infect (Larchmt) 2002;3 Suppl 1:S45-53.
Giuliano CA, Rybak MJ. Efficacy of triclosan as an antimicrobial hand soap and its potential impact on antimicrobial resistance: A focused review. Pharmacotherapy 2015;35:328-36.
Leaper D, Assadian O, Hubner NO, McBain A, Barbolt T, Rothenburger S, et al
. Antimicrobial sutures and prevention of surgical site infection: Assessment of the safety of the antiseptic triclosan. Int Wound J 2011;8:556-66.
Nooyen SM, Overbeek BP, Brutel de la Rivière A, Storm AJ, Langemeyer JJ. Prospective randomised comparison of single-dose versus multiple-dose cefuroxime for prophylaxis in coronary artery bypass grafting. Eur J Clin Microbiol Infect Dis 1994;13:1033-7.
Tamayo E, Gualis J, Flórez S, Castrodeza J, Eiros Bouza JM, Alvarez FJ, et al
. Comparative study of single-dose and 24-hour multiple-dose antibiotic prophylaxis for cardiac surgery. J Thorac Cardiovasc Surg 2008;136:1522-7.
Danda AK, Wahab A, Narayanan V, Siddareddi A. Single-dose versus single-day antibiotic prophylaxis for orthognathic surgery: A prospective, randomized, double-blind clinical study. J Oral Maxillofac Surg 2010;68:344-6.
Kang SH, Yoo JH, Yi CK. The efficacy of postoperative prophylactic antibiotics in orthognathic surgery: A prospective study in le fort I osteotomy and bilateral intraoral vertical ramus osteotomy. Yonsei Med J 2009;50:55-9.
Wahab PU, Narayanan V, Nathan S, Madhulaxmi. Antibiotic prophylaxis for bilateral sagittal split osteotomies: A randomized, double-blind clinical study. Int J Oral Maxillofac Surg 2013;42:352-5.
Lin MH, Pan SC, Wang JL, Hsu RB, Lin Wu FL, Chen YC, et al
. Prospective randomized study of efficacy of 1-day versus 3-day antibiotic prophylaxis for preventing surgical site infection after coronary artery bypass graft. J Formos Med Assoc 2011;110:619-26.
Niederhäuser U, Vogt M, Vogt P, Genoni M, Künzli A, Turina MI, et al
. Cardiac surgery in a high-risk group of patients: Is prolonged postoperative antibiotic prophylaxis effective? J Thorac Cardiovasc Surg 1997;114:162-8.
Baqain ZH, Hyde N, Patrikidou A, Harris M. Antibiotic prophylaxis for orthognathic surgery: A prospective, randomised clinical trial. Br J Oral Maxillofac Surg 2004;42:506-10.
Bentley KC, Head TW, Aiello GA. Antibiotic prophylaxis in orthognathic surgery: A 1-day versus 5-day regimen. J Oral Maxillofac Surg 1999;57:226-30.
Eshghpour M, Khajavi A, Bagheri M, Banihashemi E. Value of prophylactic postoperative antibiotic therapy after bimaxillary orthognathic surgery: A clinical trial. Iran J Otorhinolaryngol 2014;26:207-10.
Fridrich KL, Partnoy BE, Zeitler DL. Prospective analysis of antibiotic prophylaxis for orthognathic surgery. Int J Adult Orthodon Orthognath Surg 1994;9:129-31.
Jansisyanont P, Sessirisombat S, Sastravaha P, Bamroong P. Antibiotic prophylaxis for orthognathic surgery: A prospective, comparative, randomized study between amoxicillin-clavulanic acid and penicillin. J Med Assoc Thai 2008;91:1726-31.
Hall JC, Christiansen KJ, Goodman M, Lawrence-Brown M, Prendergast FJ, Rosenberg P, et al
. Duration of antimicrobial prophylaxis in vascular surgery. Am J Surg 1998;175:87-90.
Becker A, Koltun L, Sayfan J. Impact of antimicrobial prophylaxis duration on wound infection in mesh repair of incisional hernia -preliminary results of a prospective randomized trial. Europ Surg 2008;40:37-40.
Mohri Y, Tonouchi H, Kobayashi M, Nakai K, Kusunoki M; Mie Surgical Infection Research Group, et al
. Randomized clinical trial of single- versus multiple-dose antimicrobial prophylaxis in gastric cancer surgery. Br J Surg 2007;94:683-8.
Orlando G, Manzia TM, Sorge R, Iaria G, Angelico R, Sforza D, et al
. One-shot versus multidose perioperative antibiotic prophylaxis after kidney transplantation: A randomized, controlled clinical trial. Surgery 2015;157:104-10.
Oxman DA, Issa NC, Marty FM, Patel A, Panizales CZ, Johnson NN, et al
. Postoperative antibacterial prophylaxis for the prevention of infectious complications associated with tube thoracostomy in patients undergoing elective general thoracic surgery: A double-blind, placebo-controlled, randomized trial. JAMA Surg 2013;148:440-6.
Seker D, Ugurlu C, Ergul Z, Akinci M. Single dose prophylactic antibiotics may not be sufficient in elective pilonidal sinus surgery: An early terminated study. Turk Klin J Med Sci 2011;31:186-90.
Suzuki T, Sadahiro S, Maeda Y, Tanaka A, Okada K, Kamijo A, et al
. Optimal duration of prophylactic antibiotic administration for elective colon cancer surgery: A randomized, clinical trial. Surgery 2011;149:171-8.
Barton A, Blitz M, Callahan D, Yakimets W, Adams D, Dabbs K, et al
. Early removal of postmastectomy drains is not beneficial: Results from a halted randomized controlled trial. Am J Surg 2006;191:652-6.
Ackroyd R, Reed MR. A prospective randomized trial of the management of suction drains following breast cancer surgery with axillary clearance. Breast 1997;6:271-4.
Baas-Vrancken Peeters MJ, Kluit AB, Merkus JW, Breslau PJ. Short versus long-term postoperative drainage of the axilla after axillary lymph node dissection. A prospective randomized study. Breast Cancer Res Treat 2005;93:271-5.
Clegg-Lamptey JN, Dakubo JC, Hodasi WM. Comparison of four-day and ten-day post-mastectomy passive drainage in Accra, Ghana. East Afr Med J 2007;84:561-5.
Dalberg K, Johansson H, Signomklao T, Rutqvist LE, Bergkvist L, Frisell J, et al
. A randomised study of axillary drainage and pectoral fascia preservation after mastectomy for breast cancer. Eur J Surg Oncol 2004;30:602-9.
Gupta R, Pate K, Varshney S, Goddard J, Royle GT. A comparison of 5-day and 8-day drainage following mastectomy and axillary clearance. Eur J Surg Oncol 2001;27:26-30.
Inwang R, Hamed H, Chaudary MA, Fentiman IS. A controlled trial of short-term versus standard axillary drainage after axillary clearance and iridium implant treatment of early breast cancer. Ann R Coll Surg Engl 1991;73:326-8.
Kopelman D, Klemm O, Bahous H, Klein R, Krausz M, Hashmonai M, et al
. Postoperative suction drainage of the axilla: For how long? Prospective randomised trial. Eur J Surg 1999;165:117-20.
Parikh HK, Badwe RA, Ash CM, Hamed H, Freitas R Jr., Chaudary MA, et al
. Early drain removal following modified radical mastectomy: A randomized trial. J Surg Oncol 1992;51:266-9.
Strahovnik A, Fokter SK, Kotnik M. Comparison of drainage techniques on prolonged serous drainage after total hip arthroplasty. J Arthroplasty 2010;25:244-8.
Zamora-Navas P, Collado-Torres F, de la Torre-Solís F. Closed suction drainage after knee arthroplasty. A prospective study of the effectiveness of the operation and of bacterial contamination. Acta Orthop Belg 1999;65:44-7.