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’.