Individual research recommendation details

Recommendation ID

NG125/4

Question

Is the application of antiseptics and antibiotics in the operative field before wound closure, clinically and cost effective in reducing surgical site infection rates?

Any explanatory notes
(if applicable)

Why the committee made the recommendations

Limited evidence was identified on the intraoperative use of topical wound antiseptics before wound closure. Although this evidence suggested that topical povidone-iodine was effective in reducing surgical site infections, the studies were dated. This evidence also suggested that topical antiseptics, such as iodine in alcohol solution, are not effective in reducing surgical site infections.

The evidence on topical antibiotics before wound closure was varied, but also included several older studies. Some studies showed that antibiotics, such as ampicillin powder and cephaloridine, reduced the number of surgical site infections. However, the evidence for other antibiotics, such as vancomycin, which is widely used worldwide and commonly used in cardiac, orthopaedic and spine surgery, suggested no reduction in surgical site infections.

The committee agreed that the evidence was not current or clear enough to make a recommendation on the use of topical antiseptics and antibiotics before wound closure. The committee also took into account concerns about antimicrobial resistance and the potential for multidrug resistance, and agreed that without new conclusive evidence, use of intraoperative topical antibiotic and antiseptics should be stopped. They agreed that this is an important area for further research and recommended that they should be considered only in the context of further research to help limit unnecessary use and determine their clinical effectiveness. They also developed a research recommendation to determine the clinical and cost effectiveness of applying antiseptics and antibiotics before wound closure.

There was some economic evidence that antibiotic-loaded bone cement was cost effective when compared with plain cement. However, the committee were not confident that the evidence was applicable to current NHS practice. In addition, the clinical evidence suggested that antibiotic-loaded bone cement did not reduce the number of surgical site infections. The committee agreed that the evidence was too limited to make a recommendation for this intervention.

Evidence was also identified on the use of gentamicin implants before skin closure during different surgical procedures. In particular, the evidence suggested that gentamicin-collagen implants reduced the incidence of surgical site infections in people at 1 month and 2 months after cardiac surgery. Although the evidence was limited, cardiac surgery is associated with a high risk of surgical site infection, which is expensive to manage. Therefore, the committee agreed that gentamicin-collagen implants should be an option to reduce the risk of infection.

How the recommendations might affect practice

In practice, the use of topical antiseptics and antibiotics before wound closure varies. Limiting their use to clinical trials is likely to reduce their misuse in practice and encourage research in this area.

Although gentamicin-collagen implants are used in cardiac surgery, not all services currently use them. The new recommendation may help to reduce variation and standardise practice. Any additional costs are likely to be balanced by savings from a reduction in the number of surgical site infections.

Full details of the evidence and the committee's discussion are in evidence review C: intraoperative antiseptics and antibiotics before wound closure.

Source guidance details

Comes from guidance

Surgical site infections: prevention and treatment

Number

NG125

Date issued

April 2019

Other details