Surgical site infections: prevention and treatment

Preoperative phase

There is increasing evidence to support nasal decontamination of Staphylococcus aureus in patients before surgery. Topic experts thought that intranasal application of chlorhexidine had potential clinical utility, whereas there were concerns about antimicrobial resistance developing with widespread use of intranasal mupirocin. Antibiotic resistance was also a concern during development of the guideline.

Topic experts advised that the rate of surgical site infections caused by Staphylococcus aureus is low. Selective screening and decolonisation of Staphylococcus aureus in people at high risk of developing surgical site infections may be the optimum strategy. However, a full review of the evidence is necessary to determine whether current recommendations should change.

Decision: This review question should be updated.

Intraoperative phase

Currently both chlorhexidine and povidone iodine are recommended for skin antisepsis and both alcohol and water-based solutions may be used.

The evidence to inform the choice of antiseptic in surgical procedures is inconsistent. There is a lack of clarity in some abstracts about what solvents are used in the antiseptic preparations. Several studies specified the use of chlorhexidine in alcohol but did not state whether the comparator, povidone-iodine, was in alcoholic or aqueous solution. Topic experts indicated that the best choice of antiseptic is unclear. An update to this section of the guideline may provide clarity.

Decision: This review question should be updated.

In developing the guideline, 2 studies addressing the use of intraoperative gentamicin-collagen sponges were considered. However, the topic experts had concerns about potential for antimicrobial resistance and wished to see further studies in this area.

New evidence generally suggests that gentamicin-collagen sponges may reduce surgical site infections. Topic experts had differing experiences of whether gentamicin-collagen sponges are used in their hospitals. This indicates a need to evaluate whether gentamicin-collagen sponges are clinically useful.

Decision: This review question should be updated.

The guideline evaluated the evidence for different suture materials but was unable to make any recommendations based on the evidence at that time. Topic experts thought that the evidence base has grown sufficiently to allow consideration of specific types of sutures for particular surgeries. There is considerable interest in antibiotic sutures in particular.

Decision: This review question should be updated.

Questions to be considered in other guidelines

In surveillance of this guideline, we identified several areas in which interventions could have wider effects on patients than influencing surgical site infections. With advice from topic experts, we decided that certain sections of the guideline should be covered in a new guideline to be developed on perioperative care. This will allow the interventions to be considered for their effects on wider clinical outcomes than surgical site infection alone. On publication of the guideline on perioperative care, any superseded recommendations in the guideline on surgical site infection should be withdrawn. The sections to be considered in the perioperative care guideline are:

Other clinical areas

We also found evidence that was not thought to have an effect on current recommendations. This evidence related to: preoperative hair removal; theatre attire; mechanical bowel preparation; hand jewellery and decorations; and hand decontamination.

Equalities

No equalities issues were identified during the surveillance process.

Overall decision

After considering all the evidence and views of topic experts, we decided that a partial update is necessary for this guideline.

See how we made the decision for further information.