New guidelines on surgical site infections (SSIs) from the World Health Organization (WHO) say antibiotics should be used to prevent infection before and during surgery, but not after.
That advice is among the 29 recommendations provided in the WHO's Global Guidelines for the Prevention of Surgical Site Infection, which were put together by 20 leading experts on infection control. The experts also recommend that patients about to undergo surgery should not be shaved, a routine procedure that was long thought to be necessary but now appears to have no benefit, and may even heighten the risk of creating cuts and micro-abrasions that are susceptible to bacteria.
The new guidelines aim to reduce the global burden of SSIs, which occur when bacteria enters a patient's body through incisions made during surgery.
While most people who undergo surgery do not develop an infection, WHO officials estimate that millions of people globally—including 1 out of 10 in low- and middle-income nations—become infected after a surgical procedure. In Africa, up to 20% of women who undergo cesarean sections contract a wound infection, endangering both the life of the mother and of the baby.
"These result in hundreds of thousands of extra hospital days, billions of dollars in extra hospital costs, and tens of thousands of deaths," Ed Kelley, MD, the director of the WHOs Department of Service Delivery and Safety, told reporters. "These new guidelines will help keep you and your family safe."
Kelley noted that his mother died from an SSI contracted after undergoing a liver transplant at a hospital in New York.
"Despite the best liver transplant surgical team in America at the time, and a battery of antibiotics, she died from what was basically a preventable infection," Kelley said.
First international guidelines
The WHO says these are the first evidence-based international guidelines for SSI prevention, are valid for all countries, and take into account cost and resource implications. While many countries have provided guidance on SSI prevention, the agency says, there are often inconsistencies in the interpretation of evidence and recommendations. The primary target audience is surgeons and other professionals involved in surgical care.
"We hope that they'll have an impact on a wide range of healthcare settings, from operating rooms in Newcastle to health centers in Niger," Kelley said.
The guidelines include 13 recommendations for the period before surgery and 16 recommendations for preventing infections during and after surgery. They call for patients to shower or bathe before surgery, for the skin of the surgery site to be prepared with an alcohol-based antiseptic solution, and for doctors to scrub their hands with a suitable antimicrobial soap or alcohol-based hand rub before putting on surgical gloves. The panel also recommends the use of either sterile, disposable non-woven or of sterile, reusable woven drapes and gowns.
Addressing resistance issues
The guidelines also address another significant area of concern for the WHO—antibiotic resistance. While preventing infections from happening in the first place is important for reducing the spread of drug-resistant superbugs, the recommendation that antibiotics be used to prevent infections only before and during surgery, and not after, is seen as a crucial measure in efforts to reduce the overuse of antibiotics.
"Overuse, like post-operatively, increases the selective pressure for the emergence of drug-resistant infections," Dame Sally Davies, MD, Chief Medical Officer for the British government, told reporters. "This is a key piece of advice across the world."
Davies, who has been a prominent advocate of antimicrobial stewardship, said the advice truly speaks to optimizing, rather than discouraging, the use of antibiotics. "Not denying them, but using them when they'll have an impact and not drive resistance," she said.
Timing of antibiotics
Timing is a key issue. Based on the evidence examined, the panel recommends systemic antibiotic prophylaxis (SAP) be administered 2 hours before incision, mainly for major operations like bowel surgery, cesarean section, and joint replacement but not for minor surgeries.
The purpose of this recommendation, Davies explained, is to ensure that the maximal level of the drug is in the blood at the time of incision and can kill any bugs that come in. Studies have shown that patients receiving antibiotic prophylaxis within the 2-hour window have lower SSI rates than those who receive it more than 3 hours before surgery.
Antibiotics can also be used during an operation, if necessary, especially in procedures that last several hours. The choice of antibiotics is up to the physician and depends on the patient and the procedure. But the evidence the panel examined, Kelley noted, did not show that the use of antibiotics after surgery prevents infections. "This is a change in practice," he said.
Experts in antibiotic resistance welcomed the new guidelines. "If implemented effectively, it certainly will help reduce SSI and resistance; the latter because inappropriate use of prophylaxis—whether unnecessary, too broad spectrum or for too long—will all drive resistance," Dilip Nathwani, OBE, honorary professor of infection at the University of Dundee and president of the British Society for Antimicrobial Chemotherapy, told CIDRAP News.
"A lot of the guidance exists, but it brings it into one place and also provides clinical teams some steer…where practitioners are uncertain."
See also:
Nov 2016 WHO global guidelines for the prevention of surgical site infection
Nov 3 WHO press release
