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. 2018 Sep 13;13(9):e0203354. doi: 10.1371/journal.pone.0203354

Table 3. Levels of evidence for recommendations for SSI prevention as reported in included CPGs.

Recommendationsa CDC 1999 & 2017b update NICE 2008 & 2014 update WHO 2016 Strategies to Prevent SSI 2008 & 2014 Bulletin of the American College of Surgeons 2016 University of Toronto 2017
Pre-operative phase
1. Showering/bathing 1B
1B, NR
1+
NFR
Moderate
WG WG
2. Hair removal 1A
1+
NFR
Moderate A-I
WG Moderate
3. Antibiotic prophylaxis 1A-1B
1A, 1B, NR
1+, 1-
Low–Moderate A-I, A-II, B-II
I, II
WG Very low–High
4. Nasal decontamination NR
1+
Moderate
WG
5. Mechanical bowel preparation 1A
1+
Moderate
WG
6. Surgical site antimicrobial skin preparation 1B-2

Very low–Moderate A-II
I
WG Low–Moderate
7. Patient theatre attire
4


Pre-operative and/or Intra-operative phase
1. Patient Homeostasis:
    • Glycaemic control 1B
1A, NR
1-
Low A-II
I, II
WG
    • Enhanced nutritional support NR

Very low A-I
I

    • Pre-warming


WG Very low–Moderate; WG
    • Oxygenation NR
1A, NR
1+, 1-
NFR
Moderate
I

    • Discontinuation of immune-suppressants NR

Ortho: 1A, NR

Very low C-II
III

Intra-operative phase
1. Optimal timing for antibiotics 1A
1B, NR
2+
A-I
II
Very low–Moderate
2. Surgical attire, incisor drapes and gowns 1B, NR
2
Ortho: NR
1+, 4
NFR
Very low–Moderate
I, III
WG
3. Disposable versus reusable drapes and gowns



4. Surgical scrub/hand antisepsis 1B-NR
1+, 4
A-II
II, III
WG
5. Surgical site antiseptic skin asepsis 1A, 1B
1A, 2, NR
1+, 1-
NFR
A-II
I

6. Diathermy versus scalpel for surgical incision
1+
NFR
A-III
III

7. Incisional wound irrigation & intra-cavity lavage 1B
2, NR
1+, 1-
Very low–Low
II
WG
8. Antiseptic/antimicrobial agents prior to wound closure
1B, NR
1+
NFR


9. Closure methods
    • Antimicrobial sutures
2

Moderate
II
WG Moderate
    • Suture glue



10. Selection of wound dressings
    • Prophylactic NPWT


Low

11. Room traffic & ventilation 1B, 2
4
Very low–Low B-II, C-I
III

12. Decontamination of:
    • Environment & medical devices 1B-NR

A-III, B-III

    • Surgical instruments 1B

B-I
II
WG
13. Prevention of biofilm

Ortho: NR



Post-operative phase
1. Surgical antibiotic prophylaxis prolongation
1A
Ortho: 1A

Moderate A-I
II
WG Moderate–High
2. Timing of dressing changes 1B, NR


WG
3. Postoperative wound cleansing
1+, 4

WG
4. Topical antimicrobial agents for wound healing by primary intention
1+

WG
5. Dressings for wound healing by secondary intention
1-


6. Wound debridement
1-
A-III

7. Use of advanced dressings

Low

8. Wound related analgesia



9. Specialist wound care services
4


10. Antibiotic treatment of SSI & treatment failure
4


Documentation
1. Surgical wound classification 1B, 2



2. Record variables associated with increased SSI risk 1B



3. Calculation of operation-specific SSI rates 1B

A-II
II, III

4. Report SSI rates to surgical team members 1B

A-II
II

Patient/family education
1. Incision care/management 2



2. Symptoms/recognising/reporting SSI 2

A-III
III

3. Smoking cessation 1B

A-II
I
WG
4. Discharge planning
1+, NR


Not reported,—; No recommendation/unresolved issue, NR; No further recommendation, NFR; Working group expert opinion, WG; CPG, clinical practice guideline; NICE, National Institute for Clinical Excellence; WHO, World Health Organisation; SSI, surgical site infection; NPWT, negative pressure wound therapy.

aRefer to S4 Table for an explanation of the different evidence levels and S5 Table for the recommendation from each CPG that informed Table 3.

bThe 2017 CDC updated CPGs have a heavy focus on prosthetic joint arthroplasty (PJA); specifically, recommendations 11.A – 20.D. We have identified these recommendations in the CDC column by labelling them ‘Ortho’.