Table 2.
Evidence-based care bundle elements.
Adapted from lecture “A Speciality or Global Approach to SSI Prevention: Clean, Clean-Contaminated and Contaminated Procedures” delivered by Dr Charles E Edmiston, Jr., at the APAC Surgical Site Infection Prevention Symposium (Singapore, 31 July 2019)
| Bundle elements | Classa | Mechanistic benefits |
|---|---|---|
| Evidence-based interventions | ||
| Normothermia | 1A | Less bleeding/preserve immune function in wound bed/enhanced wound healing |
| Perioperative weight-based antimicrobial prophylaxis | 1A | Tissue antisepsis/intraoperative conc > MIC [90] wound pathogens |
| Glycaemic control | 1A | Preserve granulocytic immune function/enhance wound healing |
| Antimicrobial (triclosan) coated sutures (fascia/subcuticular closure) | 1A | Mitigate nidus of infection/local tissue antisepsis |
| Preadmission CHG showering/bathing | 1B | Skin antisepsis/reduce skin bioburden |
| Perioperative skin prep with 2% CHG/70% alcohol | 1A | Skin antisepsis/reduce skin bioburden |
| Separate wound closure tray | II | Mitigate instrument contamination |
| Glove change prior to fascia/subcuticular closure | II | Disrupt cross-contamination across tissue planes |
| Supplemental evidence-based interventions | ||
| Supplemental oxygen (colorectal surgery) | 1A | Enhanced tissue oxygenation and immune function/ metabolic benefits/wound healing |
| Oral antibiotics/mechanical bowel prep (colorectal surgery) | 1A | Reduce bioburden within the bowel lumen and on brush border surfaces |
| Wound edge protector (colorectal, vascular and OB/GYN surgeries) | 1B | Intraoperative wound antisepsis/minimising wound contamination |
| Staphylococcal decolonization (orthopaedic and CT surgeries) | 1A | Mitigate S. aureus and MRSA pathogenicity |
| Smoking cessation (orthopaedic, neurological, CT, and likely all surgeries) | 1B | Preserve angiogenesis/reduce risk of dehiscence/enhance wound healing |
| Intraoperative irrigation of the surgical wound with 0.05% CHG | II | Mitigate wound contamination prior to closure |
| OR traffic control – minimize door openings | No recommendation/unresolved | Reduce OR air bioburden |
CHG, chlorhexidine gluconate; CT, cardiothoracic; MRSA, methicillin-resistant Staphylococcus aureus; OB/GYN, obstetrics/gynaecology; OR, operating room, conc > MIC [90], concentration greater than the minimal inhibitory concentration required to inhibit the growth of 90% of surgical wound pathogens
aColumn 2: Interventional evidence-based criteria derived from “CDC SSI Guidelines Evidence-Based Criteria documentation and Wisconsin Division of Public Health Service Supplemental Guidance for the Prevention of Surgical Site Infections: An Evidence-based Perspective [60–62]. CDC categories: 1A = strong recommendation supported by high to moderate–quality evidence suggesting net clinical benefits or harms; 1B = strong recommendation supported by low-quality evidence suggesting net clinical benefits or harms or an accepted practice (eg, aseptic technique) supported by low to very low–quality evidence; 1C = A strong recommendation required by state or federal regulation; Category II = weak recommendation supported by any quality evidence suggesting a trade-off between clinical benefits and harms; No recommendation/unresolved issue = An issue for which there is low to very low–quality evidence with uncertain trade-offs between the benefits and harms or no published evidence on outcomes deemed critical to weighing the risks and benefits of a given intervention