Background
Materials and methods
Main topics | Statements |
---|---|
1) How to close a surgical incision? | Statement 1.1: There is no significant difference in terms of SSI incidence and length of hospital stay between patients in which the skin is sutured by continuous versus interrupted stitches (GoR 1B) Statement 1.2: Superficial wound dehiscence is lower in subcuticular continuous suture versus interrupted stitches. (GoR 1B) Statement 1.3: The use of steri-strips doesn't reduce the incidence of SSI |
2) Coated sutures: are they useful? | Statement 2: Triclosan-coated sutures significantly reduce SSI prevalence compared with the non-coated sutures (GoR1B) |
3) What is the role of intraoperative intraperitoneal irrigation vs topic wound lavage with antibiotic solutions to prevent surgical site infections? | Statement 3: There are insufficient data to to support the role of intraperitoneal the role of intraperitoneal or topic wound irrigation with antibiotics in preventing SSI |
4) Could wound irrigation with saline and/or povidone iodine solution be useful to prevent surgical site infections? | Statement 4: There are insufficient data to determine the role of saline or povidone solution irrigation of incisional wounds before closure to prevent SSI (GoR 2B). |
5) Are wound protector devices useful? | Statement 5.1: The use of wound protectors has protective effects in reducing incisional SSI (GoR 1A); Statement 5.2: The use of dual-ring constructed wound protectors appears to be superior to single-ring devices in preventing SSI (GoR1B). |
6) Are sterile surgical drapes useful? | Statement 6: There is no evidence that plastic adhesive incise drapes with or without antimicrobial properties are useful to decrease SSI (GoR 2C). |
7) To drain or not to drain in closing surgical incision? | Statement 7: There are insufficient data to determine the role of the use of subcutaneous drainage of incisional wounds before closure to prevent SSI in high-risk patients (GoR 2B) |
8) When is double gloving recommended? When is changing gloves recommended during an operation? | Statement 8.1: There are insufficient data to determine the role of double gloving to prevent SSI (GoR 2C). Statement 8.2: The mechanical resistance of latex gloves depends on the duration of wear. It may be beneficial for surgical team members and their protection to change gloves at certain intervals during surgery (GoR 2C). |
9) Is negative-pressure wound dressing useful to prevent surgical site infections? | Statement 9: The application of negative-pressure wound therapy in preventing SSI may be effective in reducing postoperative wound complications and it may be an option especially in patients with a high risk of SSI (GoR 2C) |
10) Is intraoperative normothermia useful to prevent surgical site infections? | Statement 10.1: Intraoperative normothermia decreases the rate of SSI (GoR 1A). Statement 10.2: The use of active warming devices in operating room is useful to keep normothermia and reduce SSI (GoR 1B) |
11) Is perioperative supplemental oxygen effective to reduce surgical site infections? | Statement 11: Perioperative hyperoxygenation does not reduce SSI (GoR 2B) |
12) Leaving the skin open for delayed primary closure can reduce SSI? | Statement 12.1: Delayed primary skin closure may reduce the incidence of SSI (GoR 2C) Statement 12.2: Delayed primary closure of a surgical incision is an option to take into consideration in contaminated abdominal surgeries, in patients with high risk of SSI (GoR 2C) |
13) When should additional antibiotic dose be administered intraoperatively? | Statement 13: Optimal knowledge and use of the pharmacokinetic/pharmacodynamic characteristics of antibiotics are important to evaluate when additional antibiotic doses should be administered intraoperatively in patients with intra-abdominal infections undergoing emergency surgery (GoR 1C) |
Grade of recommendation | Quality of supporting evidence | Implications |
---|---|---|
1A Strong recommendation, high-quality evidence | RCTs without important limitations or overwhelming evidence from observational studies | Strong recommendation, applies to most patients in most circumstances without reservation |
1B Strong recommendation, moderate-quality evidence | RCTs with important limitations (inconsistent results, methodological flaws, indirect analyses or imprecise conclusions) or exceptionally strong evidence from observational studies | Strong recommendation, applies to most patients in most circumstances without reservation |
1C Strong recommendation low-quality or very low-quality evidence | Observational studies or case series | Strong recommendation but subject to change when higher quality evidence becomes available |
2A Weak recommendation high-quality evidence | RCTs without important limitations or overwhelming evidence from observational studies | Weak recommendation, the best action may differ depending on the patient, treatment circumstances, or social values |
2B Weak recommendation moderate-quality evidence | RCTs with important limitations (inconsistent results, methodological flaws, indirect or imprecise) or exceptionally strong evidence from observational studies | Weak recommendation, the best action may differ depending on the patient, treatment circumstances, or social values |
2C Weak recommendation low-quality or very low-quality evidence | Observational studies or case series | Very weak recommendation; alternative treatments may be equally reasonable and merit consideration |
Results
How to close a surgical incision?
Statement 1.1: There is no significant difference in terms of SSI incidence and length of hospital stay between patients in which the skin is sutured by continuous versus interrupted stitches (GoR 1B).
Statement 1.2: Superficial wound dehiscence is lower in subcuticular continuous suture versus interrupted stitches (GoR 1B).
Statement 1.3: The use of steri-strips or tissue adhesives doesn't reduce the incidence of SSI (GoR 1B).
Coated sutures: are they useful?
Statement 2.: Triclosan-coated suture significantly reduces SSI prevalence compared with the non-coated sutures (GoR 1B).
What is the role of intraoperative intraperitoneal irrigation vs topic wound lavage with antibiotic solutions to prevent surgical site infections?
Statement 3: There are insufficient data to support the role of intraperitoneal or topic wound irrigation with antibiotics in preventing SSI (GoR 2B).
Could wound irrigation with saline and/or povidone iodine solution be useful to prevent surgical site infection?
Statement 4.: There are insufficient data to determine the role of saline or povidone irrigation of incisional wounds before closure to prevent SSI (GoR 2B)
Are wound protector devices useful? (Table 3)
Statement 5.1: The use of wound protectors has protective effects in reducing incisional SSI (GoR 1A);
Statement 5.2: The use of dual-ring constructed wound protectors appears to be superior to single-ring devices in preventing SSI (GoR 1B).
Author and year of publication | Type of study | Number of patients | Outcomes | GoR |
---|---|---|---|---|
Pinkney TD et al. 2013 [56] | Multicenter RCT | 760 | Wound edge protection devices do not reduce the rate of surgical site infection in patients undergoing laparotomy, and therefore their routine use for this role cannot be recommended. | 1A |
Gheorghe A et al. 2012 [57] | Systematic review and meta-analysis of 2 PCT + 10 RCT | 1933 | Wound edge protectors may be efficient in reducing SSI rates in patients undergoing open abdominal surgery | 1B |
Edwards JP et al. 2012 [58] | Meta-analysis of 6 RCT | 1008 | Wound protectors reduce rates of SSI after gastrointestinal and biliary surgery | 1A |
Mihaljevic AL et al. 2015 [59] | Systematic review and meta-analysis of 16 RCT | 3695 | Wound edge protectors significantly reduce the rate of surgical site infections in open abdominal surgery | 1B |
Zhang MX et al. 2015 [60] | Systematic review and meta-analysis of 11 RCT | 2344 | Wound edge protector reduces the incidence of SSI in patients receiving laparotomies, especially in the circumstance of dual-ring type and in contaminated incisions. In order to fully assess the effectiveness of WEP, large-scale and well-designed RCTs are still needed in the future. | 1B |
Kang SI et al. 2018 [61] | Systematic review and meta-analysis of 14 RCT | 2684 | Potentially significant benefit from impervious plastic wound protector use, greater protective effect in using dual-ring protector than a single ring | 1A |
Sajid MS et al. 2017 [62] | Systematic review and meta-analysis of 18 RCT | 3808 | Wound edge protector is associated with reduced incidence of overall SSI in clean-contaminated and contaminated wounds | 1B |
Bressan AK et al. 2018 [63] | RCT | 107 | Among adult patients with intrabiliary stents, the use of a dual-ring wound protector during pancreaticoduodenectomy significantly reduces the risk of incisional SSI. | 1A |
Are adhesive sterile surgical incise drapes useful?
Statement 6.1: There is no evidence that plastic adhesive drapes with or without antimicrobial properties are useful to decrease SSI (GoR 2C).
To drain or not to drain in closing surgical incision?
Statement 7.1: There are insufficient data to determine the role of subcutaneous drainage of incisional wounds before closure to prevent SSI in high-risk patients (GoR 2B).
When is double gloving recommended? When is changing gloves recommended during an operation?
Statement 8.1: There are insufficient data to determine the role of double gloving to prevent SSI (GoR 2B).
Statement 8.2: The mechanical resistance of latex gloves depends on the duration of wear. It may be beneficial for surgical team members and their protection to change gloves at certain intervals during surgery [GoR 2C].
Is negative-pressure wound dressing useful to prevent surgical site infections? (Table 4)
Statement 9: The application of negative-pressure wound therapy in preventing SSI may be effective in reducing postoperative wound complications and it may be an option, especially in patients with a high risk of SSI. (GoR 2C).
Author and year of publication | Type of study | Number of patients | Outcomes | GoR |
---|---|---|---|---|
Sandy-Hodgetts K et al. (2015) [88] | Systematic review and meta-analysis of 8 (RCT, pseudo-randomized trials, quasi-experimental studies, prospective and retrospective cohort studies, case control studies, and analytical cross sectional studies) | 1277 | NPWT in preference to standard postoperative dressings may be considered for closed surgical incisions in adults assessed as high-risk for SSI; further research is needed (level 1 studies—RCT) on patients identified as “at risk” in the preoperative period. | 2C |
Strugala V et al. 2017 [89] | Meta-analysis of 10 RCT + 6 prospective observational trials | 1863 | The significant reduction in SSI, wound dehiscence, and LOS on the basis of pooled data shows a benefit of the PICO single-use NPWT system compared with standard care in closed surgical incisions. | 1A |
Sahebally SM et al. 2018 [90] | Systematic review and meta-analysis of 9 studies (3 RCT and 2 prospective and 4 retrospective studies) | 1266 | Application of NPWT on closed laparotomy wounds in general and colorectal surgery is associated with reduced SSI rates but similar rates of seroma and wound dehiscence compared with conventional nonpressure dressings. | 2C |
Webster J et al. 2019 [94] | Cochrain systematic review (30 interventional studies) | 2957 | uncertainty remains about whether NPWT compared with a standard dressing reduces or increases the incidence of important outcomes such as mortality, dehiscence, seroma, or if it increases costs. Given the cost and widespread use of NPWT for SSI prophylaxis, there is an urgent need for larger, well-designed and well-conducted trials to evaluate the effects of newer NPWT products designed for use on clean, closed surgical incisions. Such trials should initially focus on wounds that may be difficult to heal, such as sternal wounds or incisions on obese patients. | 2C |
Katsuki Danno et al. 2018 [95] | Prospective study | 28 | The use of NPWT is an effective measure for preventing SSI in patients undergoing abdominal surgery for peritonitis caused by lower-gastrointestinal perforation. | 2C |
Lozano-Balderas G et al. 2017 [96] | Prospective randomized study | 81 | Statistical significance was found between infection rates of the vacuum-assisted group and the other two groups (primary closure and delayed primary closure). The infection rate in contaminated/dirty-infected laparotomy wounds decreases from 37 and 17% with primary and delayed primary closures, respectively, to 0% with vacuum-assisted systems. | 1C |