1. The World Health Organization Global Guidelines for the Prevention of Surgical Site Infection
Joseph S. Solomkin, M.D.
Professor of Surgery (Emeritus)
University of Cincinnati College of Medicine
and
Executive Director, OASIS Global

2. Surgical site infections (SSIs) have been an adverse outcome from surgery over the ages. In a time when knowledge of sterility and antibiotics did not exist, this could be expected. Why do SSIs occur in healthcare of the 21st century?

3. Surgical Site Infection Rates Through Time
ICP training ?
Hand hygiene
Site preparation
Delicate technique
Antibiotic prophylaxis
Surveillance
SCIP
SUSP
(websites accessed on 18/6/13); Polk HC Jr, Lopez-Mayor JF. Surgery. 1969;66(1):97-103; Wenzel RP et al. Am J Epidemiol. 1976;104(6):645-51; Cruse P. Rev Infect Dis. 1981;3(4):734-7; Bratzler DW. Clin Infect Dis. 2013;56(3):428-9; Rasley D et al. Infection 1988;16(6):373-8.
Organization and operation of the hospital-infection-control program of the University of Iowa Hospitals and Clinics.
Rasley D, Wenzel RP, Massanari RM, Streed S, Hierholzer WJ Jr.
Infection. 1988;16(6):373-8.
ICP: infection control and prevention
SCIP: surgical care improvement project
SUSP:Surgical Unit-Based Safety Program

4. Background: Impact Burden-US
~300,000 SSIs/yr (17% of all HAI; second to UTI)
2%-5% of patients undergoing inpatient surgery
Mortality
3 % mortality
2-11 times higher risk of death
75% of deaths among patients with SSI are directly attributable to SSI
Morbidity
long-term disabilities
Anderson DJ, etal. Strategies to prevent surgical site infections in acute care hospitals.
Infect Control Hosp Epidemiol 2008;29:S51-S61 for individual references

5. Relative Incidence of Hospital-Acquired Infections
Clostridium difficile-associated disease
Central line-associated bloodstream infections (CLABSI)*
Ventilator-associated pneumonia (VAP)†
Surgical Site infection
* Total BSI adjusted to estimate CLABSI (248,678 x ) = 92,011
† Total pneumonia infections adjusted to estimate VAP (250,205 x ) = 52,543
Scott RD, The Direct Medical Costs of Healthcare-Associated Infections in US Hospitals and the Benefits of Prevention. Available at (accessed on 18/6/13)
* Total BSI adjusted to estimate CLABSI (248,678 x ) = 92,011
** Total Pneumonia infections adjusted to estimate VAP (250,205 x ) = 52,543
*** Total UTIs adjusted to estimate CAUTI (561,667 x ) = 449,334
OK to redraw
SSI: surgical site infection

6. Background: Impact Length of Hospital Stay Cost
~7-10 additional postoperative hospital days
Cost
$3000-$29,000/SSI depending on procedure & pathogen
Up to $10 billion annually
Most estimates are based on inpatient costs at time of index operation and do not account for the additional costs of rehospitalization, post-discharge outpatient expenses, and long term disabilities
Anderson DJ, etal. Strategies to prevent surgical site infections in acute care hospitals.
Infect Control Hosp Epidemiol 2008;29:S51-S61 for individual references

7. Key Elements in Reducing SSI

8. It Takes Culture Change to Get the Most Out of Best-Practices
Culture change is critical to improving briefings and debriefings
Example: WHO Surgical Safety Checklist
Significant reductions in mortality and morbidity
50% of reductions were associated with the amount of culture change in the sites
Haynes, et al., 2009

9. What is a Surgical Site Infection (SSI)?
SSK symposium: Surgical Wound Sepsis
09/07/2011
What is a Surgical Site Infection (SSI)?
CDC/NHSN definition of SSI: “Infection occurring at the operation site within 30 days of the procedure.”
ref: Horan TC, Am J Inf Cont 2008
Less severe, but harder to reliably diagnose
COMPLEX SSI: More severe, straightforward diagnosis
A Aiken + A Wanyoro - Introduction to Surgical Sepsis + Work at Thika Hospital

10. Examples of Surgical Site Infections

11. Complex Surgical Site Infections and the Devilish Details of Risk Adjustment Deverick J. Anderson, MD, MPH; Luke F. Chen, MBBS; Daniel J. Sexton, MD; Keith S. Kaye, MD, MPH
Complex SSIs are serious infections that typically require rehospitalization, return to the operating room, and intravenous antibiotic therapy.
Such infections are difficult to ignore or miss when they do occur, and they are of undoubted significance to patients and their surgeons.
Infect Control Hosp Epidemiol 2008; 29:
This is the problem. 2 incision sites. Both incisions made by the same team on the same day, under the same conditions. One has a debilitating, preventable infection.

12. Why Bother with a New Guideline in Infection Control?
The broad goal of health care is to safely improve the quality of life for our community
This is now phrased as creating a culture of safety
Guidelines are intended to establish “best practices” to achieve this
Appropriate topics include:
The structure for administered services (Core Components)
The communication skills of health care workers
The details of technical care (this guideline)

13. 72% of the surgeries performed in the developing world are emergency surgeries.Emergency surgeries are riskier and procedures are often skipped.There is a huge need for our solution.

14. Incidence of SSIs/100 Procedures in Low and Middle Income Countries90 80 70 60
Cumulative incidence of surgical-site infection (per 100 surgical procedures) 50 40 30 20 10
Clean- contaminated
Clean
Contaminated
Dirty
Wound Classification
Allegranzi, B. et al. Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis. Lancet (London, England) 377, (2011).

15. SSI Prevention Guidelines – WHO Perspectives
Need for updated, evidence-based guidelines
Valid for any country, but including specific issues depending on regional differences and/or peculiar to low-/middle-income countries
Strong component on implementation strategies and surveillance
Associated implementation tools

16. Global Guidelines for the Prevention of Surgical Site Infection
The World Health Organization (WHO) Global Guidelines for the Prevention of Surgical Site Infections provide a comprehensive range of evidence-based recommendations that take account of:
the global perspective
the evidence quality level
cost and resource implications (including for low and middle income countries)

17. Guideline Development Group
Co-Chairs: Didier Pittet and Joseph Solomkin
Hanan Balkhy Marja A. Boermeester Nizam Damani E. Patchen Dellinger Mazen Ferwana Petra Gastmeier Xavier Guirao Nordiah Awang Jalil Robinah Kaitiritimba
Claire Kilpatrick
Shaheen Mehtar
Regina Namata Kamoga
Babacar Ndoye
Peter M. Nthumba
Leonardo Pagani
Jianan Ren
Akeau Unahalekhaka
Andreas Widmer
Matthias Egger

18. Sources for the WHO SSI Prevention Guidelines and Associated Documents
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. The Lancet Infectious Diseases 2016;16:e276-e87.
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. The Lancet Infectious Diseases 2016;16:e288-e303.

21. Grading of Recommendations Assessment, Development and Evaluation
RATING
EVIDENCE STATEMENT
HIGH
We are very confident that the true effect lies close to the estimate of effect
MODERATE
We are moderately confident in the effect estimate; there is a possibility that the true effect is substantially different
LOW
Our confidence in the effect estimate is limited
VERY LOW
We have very little confidence in the effect estimate
According to a standard GRADE decision making table proposed by the methodologist, recommendations were formulated based on the overall quality of the evidence, the balance between benefits and harms, values and preferences
and implications for resource use.

22. Grading of Recommendations Assessment, Development and Evaluation
RATING
RECOMMENDATION STATEMENT
STRONG
the panel was confident that the benefits outweighed the risks
CONDITIONAL
the panel considered that the benefits of the intervention probably outweighed the risks
According to a standard GRADE decision making table proposed by the methodologist, recommendations were formulated based on the overall quality of the evidence, the balance between benefits and harms, values and preferences
and implications for resource use.

23. WHO CDC ANTIBIOTIC PROPHYLAXIS
When indicated (depending on the type of operation), surgical antibiotic prophylaxis should be administered prior to the surgical incision.
Surgical antibiotic prophylaxis should be administered within 120 minutes before incision, while considering the half-life of the agent
Strong recommendation
Moderate quality of evidence
Surgical antibiotic prophylaxis administration should not be prolonged after completion of the operation for the purpose of preventing SSI
Administer preoperative antimicrobial agents only when indicated and based on published clinical practice guidelines and timed such that a bactericidal concentration of the agents is established in the
serum and tissues when the incision is made.
Strong recommendation; accepted practice
Do not administer additional prophylactic antimicrobial agent doses after the surgical incision is closed in the operating room, even in the presence of a drain.
high-quality evidence
Hawn MT, Richman JS, Vick CC, et al. Timing of surgical antibiotic prophylaxis and the risk of surgical site infection. JAMA surgery 2013;148:

24. WHO
CDC
HAIR REMOVAL
In patients undergoing any surgical procedure, hair should either not be removed or, if absolutely necessary, it should be removed only with a clipper.
Shaving is strongly discouraged at all times, whether preoperatively or in the
operating room
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)

25. WHO CDC PREOPERATIVE BATHING
Patients should bathe or shower before surgery; either a plain soap or an antimicrobial soap may be used for this purpose
Conditional recommendation
moderate quality of evidence
Advise patients to shower or bathe (full body) with soap (antimicrobial or nonantimicrobial) or an antiseptic agent on at least the night before the operative day.
Strong recommendation
accepted practice
SURGICAL SITE PREPARATION
Alcohol-based antiseptic solutions based on CHG for surgical site skin preparation
should be used in patients undergoing surgical procedures
moderate to low quality of evidence
Perform intraoperative skin preparation with an alcohol-based antiseptic agent unless contraindicated.
Strong recommendation;
high-quality evidence

26. WHO
CDC
PERIOPERATIVE OXYGENATION
Adult patients undergoing general anaesthesia with endotracheal intubation for surgical procedures should receive FiO2 80% intraoperatively and, if feasible, in the immediate postoperative period for 2-6 hours
Strong recommendation
Moderate quality of evidence
Randomized controlled trial evidence suggested uncertain tradeoffs between the benefits and harms regarding the administration of increased fraction of inspired oxygen (FIO2) via endotracheal intubation during only the intraoperative period in patients with normal pulmonary function undergoing general anesthesia for the prevention of SSI
No recommendation
unresolved issue

27. WHO
CDC
GLYCEMIC CONTROL
Protocols are suggested to be used for intensive perioperative blood glucose control for both diabetic and non-diabetic adult patients undergoing surgical procedures
Conditional recommendation (low)
Implement perioperative glycemic control and use blood glucose target levels less than 200 mg/dL in patients with and without diabetes.
Strong recommendation
high to moderate– quality evidence
NORMOTHERMIA
Warming devices are suggested for use in the operating room and during the surgical procedure for patient body warming
Conditional recommendation
(moderate)
Maintain perioperative normothermia
high to moderate–quality evidence

28. WHO
CDC
ANTIMICROBIAL IRRIGATION
Antibiotic incisional wound irrigation before closure should not be used
Conditional
2A.1. Randomized controlled trial evidence suggested uncertain
trade-offs between the benefits and harms regarding intraoperative
antimicrobial irrigation

29. WHO CDC TRICLOSAN-COATED SUTURES
Triclosan-coated sutures are suggested to be
used in all types of surgery
Conditional
recommendation
(moderate)
Consider the use of triclosan-coated sutures for the prevention of SSI.
Weak recommendation; moderate-quality evidence
suggesting a trade-off between clinical benefits and harms.
ANTIMICROBIAL DRESSINGS
No type of advanced dressing should be used
over a standard dres
Conditional recommendation
(low)
Randomized controlled trial evidence suggested uncertain tradeoffs between the benefits and harms regarding antimicrobial dressings applied to surgical incisions after primary closure in the operating room for the prevention of SSI.
No recommendation/ unresolved issue

30. Other Recommendation Areas
Laminar flow ventilation systems in the context of operating room ventilation
Prophylactic negative pressure wound therapy
Wound protector devices
Drapes and gowns
Maintenance of adequate circulating volume control/ normovolemia
Drains

31. “Never doubt that a small group of thoughtful committed people can change the world, for indeed, it is the only thing that ever has.” - Margaret Meade