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Prevention from the start

What is the best available evidence regarding preoperative evaluation and preventive measures to control surgical site infection?

Clinical bottom line
Surgical site infection (SSI) is a serious complication of surgery and may be associated with increased length of hospital stay for the patient and higher hospital costs. Prevention of SSI begins with the preoperative evaluation at the time of the surgical or other consultation.1

Medical history and risk assessment
• In addition to obtaining a thorough medical history and performing a routine physical examination, a nutritional assessment of the patient is important in the evaluation of the risk for an SSI.1
• Patient characteristics associated with an increased risk of an SSI include coincident remote site infections or colonisation, diabetes, cigarette smoking, systemic steroid use, obesity (>20 per cent ideal body weight), extremes of age, poor nutritional status, and perioperative transfusion of certain blood products.1

Preoperative preparation

Hair removal
Body hair removed from the intended surgical wound site is thought to reduce the chance of SSI. Three methods of hair removal are currently used; shaving with a razor, clipping with clippers and using a cream which dissolves the hair.2

A systematic review found that removing hair before surgery using cream results in fewer surgical site infections than shaving. However, if it is necessary to remove hair then it is preferable to use clippers rather than shaving with a razor as this results in fewer surgical site infections.2

Preoperative bathing or showering
Preoperative bathing or showering with an antiseptic skin wash product is a well-accepted procedure for reducing skin bacteria (microflora). A systematic review did not show clear evidence of benefit for the use of chlorhexidine solution over other wash products.3

Skin antiseptics
Preoperative skin antisepsis is performed to reduce the risk of post-operative wound infections by removing soil and transient organisms from the skin. The effectiveness of preoperative skin preparation is dependent on both the antiseptic used and the method of application.4
A systematic review identified that infection rates were significantly lower when skin was prepared using chlorhexidine compared with iodine, and no evidence of a benefit associated with the use of iodophor impregnated drapes.4

Antimicrobial prophylaxis (AMP)
AMP is a critically timed adjunct used to reduce the microbial burden of intraoperative contamination. Intravenous infusion is the mode of AMP delivery used most often in modern surgical practice.1 A systematic review showed that antibiotic prophylaxis reduces the risk of developing bacterial resistance, it is effective in the prevention of postoperative infection in appendectomies, and regardless whether the antibiotic was given before, during or after the surgery.5 The other systematic review determined the effectiveness of perioperative strategies to prevent infection in patients undergoing peripheral arterial reconstruction found that systemic antibiotics commenced immediately pre-operatively, reduced the risk of wound infection and certainly early graft infection by between three-quarters and two-thirds.6
Many of the recommendations for surgical prophylaxis are cephalosporins. There is often a concern about giving cephalosporins to patients with known penicillin allergy.1

Mechanical bowel preparation for colorectal surgery
Preoperative mechanical bowel preparation before colorectal surgery is a widely-practised treatment. A systematic review found that there is no convincing evidence that mechanical bowel preparation is associated with reduced rates of anastomotic leakage after elective colorectal surgery, but on the contrary, there is evidence that this intervention may be associated with an increased rate of anastomotic leakage and wound complications.7

Glycaemic control
Determination of a patient's glycaemic control status is an important factor in preventing SSI. In diabetics, outcomes are improved in patients with preoperative glycated haemoglobin A1C (HbA1c) less than 7.1

Normothermia management
Hypothermia in the perioperative setting is associated with a higher risk of SSI. Monitoring and documenting patient core temperature throughout the perioperative period should be routinely performed.1

Patient education
Patient education on surgical procedure and a general orientation is part of the preoperative evaluation. This includes education on which medications they should continue to take, how their medications and conditions will be managed during their surgical procedures, and how long before the surgery to have nothing by mouth.1

Best practice recommendations
• It is recommended that preoperative evaluation include medical history (including past surgical infections), physical examination, preoperative diagnostic testing based on patient and surgical risk indications, and patient education.
• It is suggested when IgE-suspected reaction to penicillin or amoxicillin has been identified, only cephalosporins with related side chains should be avoided. Other cephalosporins can be given.
• Patients who have been identified as being carriers for methicillin resistant Staphylococcus Aureus (MRSA), at high risk for being colonised with MRSA, or previously infected with MRSA should have this noted in their medical record.

1. Beilman G, Hayes K, Kosmatka P, Hay L, Trygstad C, Matteson M, et al. Institute for Clinical Systems Improvement (ICSI). Health care protocol: prevention of surgical site infection. 1st ed. Bloomington (US): ICSI; 2006.
2. Tanner J, Woodings D, Moncaster K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev. 2006, Issue 3.
3. Webster J, Osborne S. Preoperative bathing or showering with skin antiseptics to prevent surgical site infection. Cochrane Database Syst Rev. 2007, Issue 2.
4. Edwards PS, Lipp A, Holmes A. Preoperative skin antiseptics for preventing surgical wound infections after clean surgery. Cochrane Database Syst Rev. 2004, Issue 3.
5. Andersen BR, Kallehave FL, Andersen HK. Antibiotics versus placebo for prevention of postoperative infection after appendicectomy. Cochrane Database Syst Rev. 2005, Issue 3.
6. Stewart A, Eyers PS, Earnshaw JJ. Prevention of infection in arterial reconstruction. Cochrane Database Syst Rev. 2006, Issue 3. (Level I)
7. Guenaga K, Atallah AN, Castro AA, Matos DDM, Wille-Jørgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Syst Rev. 2005, Issue 1.

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