Overview of the WHO global guidelines for the prevention of surgical site infection Dr. Mohamed Abbas, MD, MS Semmelweiss CEE Conference Budapest 08.03.2017
Outline of presentation General background Burden of surgical site infection (SSI) isk factors for SSI ationale & development of the guidelines Overview of the recommendations Conclusion
Outline of presentation General background Burden of surgical site infection (SSI) isk factors for SSI ationale & development of the guidelines Overview of the recommendations Conclusion
Surgical Site Infection (SSI) About 80 000 hospitalised patients in Europe have at least one HAI on any given day In Europe, SSI are the second most frequent type of HAI (19.6%) 543 149 (298 167-1 062 673) SSI episodes/year (HAI prevalence survey 2011) In the US, the overall SSI rate was 0.9% in 2014 (data from 3654 hospitals over 2 417 933 surgical procedures) SSI are the most frequent type of HAI on admission (67% in US, 33% in Europe) Surgical sepsis accounts for approximately 30% of all septic patients SSI are the most frequent type of HAIs in LMICs and rates are significantly higher than in HICs (11%, on average) Courtesy: Prof. B. Allegranzi
University of Geneva Hospitals 2007-2012 GI BSI SST acute care Other SSI 24% Figure courtesy of Walter Zingg LTI UTI ENT LTI Other SST BSI UTI SST Systemic GI BSI Other SSI SSI pneumonia Pneumonia /LTI GI 22% UTI 20% Zingg et al. InfectControl Hosp Epidemiol 2014;35:674 Magill et al. N Engl J Med. 2014 Mar 27;370(13):1198-20 ECDC. Point prevalence survey of healthcare-associated infections and antimicrobial use in European acute care hospitals. Stockholm: ECDC; 2013
SSI burden in low-/middle-income countries Allegranzi B et al. Lancet 2011;377:228-41 Published on 5 May 2011 http://www.who.int/gpsc/en/ Courtesy: Prof. B. Allegranzi Bagheri Nejad S, et al. Bull OMS 2011;89:757-765
SSI cumulative incidence by operation type 2008-2011 9.2% 54% 3.5% 1.4% 2.7% 1% 0.7% 0.8% ECDC Annual Epidemiological eport 2013
SENIC study Study on the Efficacy of Nosocomial Infection Control Haley W et al. Am J Epidemiol 1985;121(2):182-205 elative change in NI in a 5 year period (1970-1975) 30% 20% 10% 0% -10% Without infection control 14% 9% 19% 26% 18% LTI SSI UTI BSI Total 50% -20% -30% -40% -27% -31% -35% With infection control -35% -32% Courtesy: Prof. Didier
inadequate antibiotic prophylaxis colonisation with nosocomial pathogens poor hand hygiene inadequately sterilized/disinfected equipment inadequate skin antisepsis hypothermia skin shaving increased O traffic prolonged pre-operative stay inadequate timing of antibiotic prophylaxis prolonged operative duration contaminated antiseptics poor surgical technique poor oxygenation emergency procedure hyperglycaemia prosthetic implants inadequate ventilation inadequate attire
Outline of presentation General background Burden of surgical site infection (SSI) isk factors for SSI ationale & development of the guidelines Overview of the recommendations Conclusion
Main reasons for developing the guidelines High global epidemiological burden Highly preventable infection No recent -based guidelines Need for a global perspective Need for taking into account balance between benefits and harms, quality level, cost and resource use implications, and patient values and preferences Courtesy: Prof. B. Allegranzi
WHO global guidelines for SSI prevention Courtesy: Prof. B. Allegranzi
WHO GLOBAL SSI PEVENTION GUIDELINES Abstracts presented at 26 th ECCMID, Amsterdam 2016 The Lancet Infectious Diseases & official launch, 2 November 2016 WHO SSI Prevention Guidelines 27 systematic reviews & meta-analysis 29 recommendations 30 core chapters Key updates on: Timing & duration of surgical ATB prophylaxis ATB use with drains S. aureus carriers decolonization Glucose control Normovolemia Oxygenation Wound irrigation Antimicrobial sutures & A LOT MOE.
WHO Global Guidelines for the Prevention of SSI Aim: To provide a comprehensive range of - and consensusbased recommendations for interventions related to the prevention of SSI during pre-, intra-, and post-operative periods Further ensure high quality care for every patient irrespective of resource availability Population: patients of any age undergoing any type of surgical procedure Target audience: the surgical team (surgeons, nurses, technical support staff, anaesthetists, and any professionals directly providing surgical care), infection prevention and control (IPC) professionals, policy-makers, senior managers, hospital administrators, as well as those responsible for staff education and training. Courtesy: Prof. B. Allegranzi
Methodology Guidelines Development Group: international multidisciplinary team of experts balance in gender, geographic representation, professional groups Topics were identified PICO questions (Population, Intervention, Comparator, Outcomes) Systematic reviews for each PICO multiple databases searched
Methodology (2) Evidence quality assessment: Cochrane Collaboration & Newcastle-Ottawa GADE (Grading of ecommendations Assessment, Development, and Evaluation) Meta-analyses Development of recommendation
Methodology (3) Strength of recommendations, based on confidence of experts regarding the : Strong : benefits outweighed risks adaptable for implementation in most (if not all) situations most patients should receive the intervention Conditional : benefits probably outweighed the risks a more structured decision-making process should be undertaken, based on stakeholder consultation and the involvement of patients and health care professionals.
Outline of presentation General background Burden of surgical site infection (SSI) isk factors for SSI ationale & development of the guidelines Overview of the recommendations Conclusion
PE-OPEATIVE MEASUES
Q Q Should immunosuppressive agents be discontinued perioperatively? Immunosuppressive medication should not be discontinued prior to surgery for the purpose of preventing SSI Conditional recommendation Very low quality of Should enhanced nutritional support be used for the prevention of SSI? Consider the administration of oral or enteral multiple nutrient-enhanced nutritional formulas for the purpose of preventing SSI in underweight patients who undergo major surgical operations. Conditional recommendation Very low quality of
Q Is preoperative bathing using an antiseptic soap more effective in reducing the incidence of SSI in surgical patients when compared to bathing with plain soap? It is good clinical practice for patients to bathe or shower before surgery. Either a plain soap or an antiseptic soap could be used for this purpose. Conditional recommendation Very low quality of Q Is preoperative bathing with CHGimpregnated cloths more effective in reducing the incidence of SSI in surgical patients when compared to bathing with antiseptic soap? No recommendation formulated due to very low quality
Q Is mupirocin nasal ointment in combination with or without a CHG body wash effective in reducing the number of S. aureus infections in nasal carriers undergoing surgery? Patients undergoing cardiothoracic and orthopaedic surgery with known nasal carriage of S. aureus should receive perioperative intranasal applications of mupirocin 2% ointment with or without a combination of CHG body wash. Strong recommendation Moderate quality of
Q Is mupirocin nasal ointment in combination with or without a CHG body wash effective in reducing the number of S. aureus infections in nasal carriers undergoing surgery? Consider also treating patients with known nasal carriage of S. aureus undergoing other types of surgery with perioperative intranasal applications of mupirocin 2% ointment with or without a combination of CHG body wash. Conditional recommendation Moderate quality of
Q Is mechanical bowel preparation (MBP) combined with or without oral antibiotics effective for the prevention of SSI in colorectal surgery? Preoperative oral antibiotics combined with MBP should be used to reduce the risk of SSI in adult patients undergoing elective colorectal surgery. Conditional recommendation Moderate quality of MBP alone (without the 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 of
Q 1. Does hair removal affect the incidence of SSI? 2. What method and timing of hair removal is associated with the reduction of SSI? In patients undergoing any surgical procedure, either hair should not be removed or, if absolutely necessary, it should be removed only with a clipper. Shaving is strongly discouraged at all times, whether preoperatively or in the operating room. Strong recommendation Moderate quality of
Q How does the timing of surgical antibiotic prophylaxis administration impact on the risk of SSI and what is the precise optimal timing? When indicated (depending on the type of operation), surgical antibiotic prophylaxis should be administered prior to the surgical incision. Strong recommendation Low quality of Surgical antibiotic prophylaxis should be administered within 120 minutes before incision, while considering the half-life of the antibiotic. Strong recommendation Moderate quality of
Q 1. What is the most effective type of product for surgical hand preparation to prevent SSI? 2. What is the most effective technique and the ideal duration of surgical hand preparation? Surgical hand preparation should be performed using either a suitable antimicrobial soap and water or a suitable alcohol-based hand rub before donning sterile gloves. Strong recommendation Moderate quality of
Q In surgical patients, should alcohol-based antiseptic or aqueous solutions be used for skin preparation and, more specifically, should CHG or PVP-I solutions be used? Alcohol-based antiseptic solutions, particularly based on chlorhexidine gluconate (CHG), are recommended for surgical site skin preparation in patients undergoing surgical procedures. Strong recommendation Low to moderate quality of
Q In surgical patients, should antimicrobial sealants (in addition to standard surgical site skin preparation) vs. standard surgical site skin preparation be used for the prevention of SSI? Antimicrobial sealants should not be used after surgical site skin preparation for the purpose of reducing SSI. Conditional recommendation Very low quality of
INTA-OPEATIVE MEASUES
Q How safe and effective is the perioperative use of increased FiO 2 in reducing the risk of SSI? Adult patients undergoing general anaesthesia with endotracheal intubation for surgical procedures should receive FiO 2 80% intraoperatively and, if feasible, in the immediate postoperative period for 2-6 hours. Strong recommendation Moderate quality of
Q In surgical patients, should systemic body warming vs. no warming be used for the prevention of SSI? Warming devices should be used in the operating room and during the surgical procedure for patient body warming with the purpose of reducing SSI. Conditional recommendation Moderate quality of
Q 1. Do protocols aiming to maintain optimal perioperative blood glucose levels reduce the risk of SSI? 2. What are the optimal perioperative glucose target levels in diabetic and non-diabetic patients? Protocols for intensive perioperative blood glucose control should be used for both diabetic and nondiabetic adult patients undergoing surgical procedures. Conditional recommendation Low quality of
Q 1. Is there a difference in SSI rates depending on the use of disposable non-woven drapes and gowns vs. reusable, woven drapes and gowns? 2. Does changing drapes during operations affect the risk of SSI? 3. Does the use of disposable adhesive incise drapes reduce the risk of SSI? Either sterile disposable non-woven or sterile reusable woven drapes and surgical gowns can be used during surgical operations. Conditional recommendation Moderate to very low quality of Plastic adhesive incise drapes with or without antimicrobial properties should not be used. Conditional recommendation Low to very low quality of
Q Does the use of wound protector devices reduce the rate of SSI in open abdominal surgery? Consider the use of wound protector devices in clean-contaminated, contaminated and dirty abdominal surgical procedures for the purpose of reducing the rate of SSI. Conditional recommendation Very low quality of
Q Does intraoperative wound irrigation reduce the risk of SSI? Saline irrigation: insufficient to recommend for or against saline irrigation of incisional wounds Aqueous povidone iodine: Consider the use of irrigation of the incisional wound with an aqueous povidone iodine solution before closure, particularly in clean and cleancontaminated wounds. Antibiotic incisional wound irrigation before closure should not be used for the purpose of preventing SSI. Conditional recommendation Low quality of
Q Does prophylactic negative pressure wound therapy reduce the rate of SSI compared to the use of conventional dressings? Prophylactic negative pressure wound therapy may be used on primarily closed surgical incisions in high-risk wounds and, taking resources into account, for the purpose of preventing SSI. Conditional recommendation Low quality of
Q Are antimicrobial-coated sutures effective to prevent SSI? If yes, when and how should they be used? Triclosan-coated sutures may be used for the purpose of reducing the risk of SSI, independent of the type of surgery. Conditional recommendation Moderate quality of
Q 1. Is the use of laminar air flow in the operating room associated with the reduction of overall or deep SSI? 2. Does the use of fans or cooling devices increase SSIs? 3. Is natural ventilation an acceptable alternative to mechanical ventilation? Laminar airflow ventilation systems should not be used to reduce the risk of SSI for patients undergoing total arthroplasty surgery. Conditional recommendation Low to very low quality of
POST-OPEATIVE MEASUES
Q 1. In the presence of drains, does prolonged antibiotic prophylaxis prevent SSI? 2. When using drains, how long should they be kept in place to minimise SSI as a complication? Perioperative surgical antibiotic prophylaxis should not be continued due to the presence of a wound drain. Conditional recommendation Low quality of The wound drain should be removed when clinically indicated. No was found to allow making a recommendation on the optimal timing of wound drain removal. Conditional recommendation Very low quality of
Q In surgical patients, should advanced dressings vs. standard sterile wound dressings be used for the prevention of SSI? Advanced dressing of any type should not be used over a standard dressing on primarily closed surgical wounds for the purpose of preventing SSI. Conditional recommendation Low quality of
Q Does continued postoperative surgical antibiotic prophylaxis reduce the risk of SSI compared with preoperative and (if necessary) intraoperative prophylaxis only? Surgical antibiotic prophylaxis administration should not be prolonged after completion of the operation for the purpose of preventing SSI. Conditional recommendation Low to very low quality of
Outline of presentation General background Burden of surgical site infection (SSI) isk factors for SSI ationale & development of the guidelines Overview of the recommendations Conclusion
Important considerations for implementation in low-resource settings Some recommendations will NOT be resource demanding or they will even allow avoidance of unnecessary costs (e.g. no antibiotic prophylaxis prolongation; no laminar flow) Some recommendations will contribute to reducing AM For others, careful evaluation should be made about: Additional costs involved and/or limited product availability (e.g. alcohol-based hand rubs, chlorhexidine gluconate alcohol-based antiseptic solutions, antimicrobial sutures) Need for staff training (e.g. increased oxygenation) Need for specific expertise (e.g. glucose control; normovolemia) Need for technical laboratory capacity (e.g. S. aureus carrier identification) Involving organisational resources for appropriate administration (e.g. antibiotic timing) euse and contamination risks (e.g. clippers) Infrastructure constraints (e.g. limited access to clean water) Local production and solutions should be encouraged Courtesy: Prof. B. Allegranzi
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http://www.who.int/gpsc/ssi-prevention-guidelines/en/
In conclusion The WHO guidelines represent a major piece of work Summarizes the best available An implemenation strategy by WHO will soon be produced
Acknowledgements Prof. Benedetta Allegranzi Infection Prevention and Control Global Unit, WHO Prof. Didier Pittet Infection Control Programme & WHO Collaborating Center, Geneva University Hospitals
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