APSIC guidelines for the prevention of surgical site infections
The Asia Pacific Society of Infection Control (APSIC) launched the APSIC Guidelines for the Prevention of Surgical Site Infections in 2018. This document describes the guidelines and recommendations for the setting prevention of surgical site infections (SSIs). It aims to highlight practical recommendations in a concise format designed to assist healthcare facilities at Asia Pacific region in achieving high standards in preoperative, perioperative and postoperative practices.
The guidelines were developed by an appointed workgroup comprising experts in the Asia Pacific region, following reviews of previously published guidelines and recommendations relevant to each section.
It recommends that healthcare facilities review specific risk factors and develop effective prevention strategies, which would be cost effective at local levels. Gaps identified are best closed using a quality improvement process. Surveillance of SSIs is recommended using accepted international methodology. The timely feedback of the data analysed would help in the monitoring of effective implementation of interventions.
Healthcare facilities should aim for excellence in safe surgery practices. The implementation of evidence-based practices using a quality improvement process helps towards achieving effective and sustainable results.
KeywordsSurgical site infection SSI Prevention Safe surgery
Alcohol-based hand rub
Asia Pacific Society of Infection Control
American Society for Testing and Materials
Center for Disease Control and Prevention
Central line associated blood stream infection
Low Middle Income Countries
Mechanical bowel preparation
Methicillin resistant Staphylococcus aureus
National Healthcare Safety Network
National Institute for Health and Care Excellence
Randomized controlled trials
South East Asia
Surgical site infection
United States of America
Vancomycin resistant Staphylococcus aureus
World Health Organization
Risk factors for SSIs
Preoperative risk factors
a. Increasing age until age 65 years
b. Recent radiotherapy and history of skin or soft tissue infection
a. Uncontrolled diabetes
b. Obesity, malnutrition
c. Current smoking
e. Preoperative albumin < 3.5 mg/dL
f. Total bilirubin > 1.0 mg/d
g. Preoperative hospital stay of at least 2 days
Perioperative risk factors
a. Emergency and more complex surgery,
b. Higher wound classification
c. Open surgery.
2. Facility risk factors
a. Inadequate ventilation,
b. Increased operation theatre traffic
c. Inappropriate/inadequate sterilization of instruments/equipment.
3. Patient preparation-related
a. A pre-existing infection
b. Inadequate antiseptic skin preparation
c. Preoperative hair removal
d. Wrong antibiotic choice, administration, and/or duration
4. Intraoperative risk factors
a. Long operating time
b. Blood transfusion
c. Asepsis and surgical technique
d. Hand/forearm antisepsis and gloving techniques
g. Poor glycaemic control.
Postoperative risk factors
1. Hyperglycaemia and diabetes
2. Postoperative wound care
The full APSIC Guidelines for the Prevention of Surgical Site Infections is available at https://apsic-apac.org as reference to guide practice. It is developed to assist countries to implement best practices to prevent SSIs esp. in low resource setting.
Review workgroup composition
APSIC convened experts in Infection Prevention and surgical discipline from Asia Pacific region to develop the APSIC Guidelines for the Prevention of Surgical Site Infections. The members of this workgroup are the authors of this paper.
Literature review and analysis
For the development of this APSIC guideline, the workgroup reviewed previously published guidelines (e.g. WHO, CDC, Cochrane, etc.) and recommendations relevant to each section and performed computerized literature searches using PubMed. Examples of key search terms used include SSI, prevention and the various topics reviewed.
Categories for strength of each recommendation
Recommendations for surveillance of surgical site infections (SSIs)
Perform surveillance of SSIs using accepted international methodology. (IIB)
Recommendations for pre-operative preventive measures
It is generally accepted that preoperative bathing with soap (antimicrobial or non-antimicrobial) is beneficial prior to surgery, despite the lack of study comparing preoperative bath versus no-preoperative bath on the occurrence of SSIs.
It is necessary for patients who will undergo surgery to have at least 1 preoperative bath with soap (antimicrobial or non-antimicrobial). (IIB)
Mechanical bowel preparation (MBP) and oral antibiotics for elective colorectal surgery in adults
Combination mechanical bowel preparation and oral antibiotic preparation are recommended for all elective colorectal surgery in adults. (IA)
There are several methods to remove hair at the surgical site preoperatively. Hair removal by shaving and the night before an operation is associated with and increased risk of SSI. Shaving and/or clipping can cause microscopic cuts in the skin that later serve as foci for bacterial multiplication [6, 7].
1. Hair removal should be avoided unless hair interferes with the operative procedure. (IIIB).
2. If hair removal is necessary, a razor should be avoided and an electric clipper should be used. (IA).
3. No recommendation regarding the timing of hair removal by clipper is made. (IIIC).
Methicillin-resistant Staphylococcus aureus (MRSA) screening and decolonization
Hospitals should evaluate their SSI, Staphylococcus aureus (S. aureus) and MRSA rates, and mupirocin resistant rate, if available, to determine whether implementation of a screening program is appropriate. (IIB)
Patients undergoing cardiothoracic and orthopedic surgery with known nasal carriage of S. aureus should receive perioperative intranasal application of mupirocin 2% ointment with or without a combination of CHG body wash. (IA)
Surgical hand/forearm preparation
Surgical hand preparation is to be performed either by scrubbing with a suitable antiseptic soap and water or a suitable ABHR before donning sterile gown and gloves. (IA)
ABHR used in surgical hand preparation should comply with EN 12791 or ASTM E-1115 standards. (IIIA)
Where the quality of water used is not assured, surgical hand rub with ABHR is recommended. (IIIB)
Alcohol based skin antiseptic preparations should be used, unless contraindicated. (IA)
Administration of prophylaxis antimicrobials should only be performed when indicated. (IA)
Prophylactic antimicrobials should be administered within 1 h before incision for all antimicrobials except vancomycin and fluoroquinolones where it should be administered within 2 h. (IA)
Re-dosing should be considered to maintain adequate tissue levels based on agent half-life. (IA)
A single dose of antimicrobial prophylactic is adequate for most surgical procedures. (IA)
Underweight patients undergoing major surgical procedures, especially oncology and cardiovascular operations, may benefit from the administration of oral or enteral multiple nutrient-enhanced nutritional formulas for the purpose of preventing SSI. (IIIC)
Preoperative HbA1C levels should be less than 8%. (IIIC)
Recommendations for intra-operative preventive measures
Maintain perioperative normothermia by using active warming devices. (IB)
Hemodynamic goal-directed therapy is recommended to reduce surgical site infection. (IA)
Wound irrigation is considered to be one of the most useful SSI prevention methods by many surgeons. We agree with WHO and NICE that there is inadequate evidence to comment on this and concur with WHO that antibiotic irrigation for SSI prevention should be avoided [35, 36].
1. There is insufficient evidence to recommend for or against saline of incisional wounds before closure for the purpose of preventing SSI. (IIC).
2. Avoid using antimicrobial agents to irrigate the incisional wounds before closure to reduce the risk of SSI. (IA).
Antimicrobial impregnated sutures
Where there are high SSI rates in clean surgeries, in spite of basic preventive measures, individual centers may consider the use of antimicrobial impregnated sutures. (IIB)
In various guidelines, it is generally accepted not to recommend non-iodine- impregnated adhesive incise drapes, since it is associated with SSI risk. However, in several observational studies especially in clean surgeries, marked SSI reduction reported with the proper use of iodine-impregnated drapes [38, 39, 40, 41, 42]. Considering the promising effect of controlling skin recolonization, and the fact that bacterial wound contamination may be directly linked to SSI, we believe that the use of iodine- impregnated adhesive incise drapes may be beneficial. Based on the above evidence, we do recommend their use when necessary, especially in orthopedic and cardiac surgeries.
1. When using adhesive incise drapes, do not use non-iodophor-impregnated drapes for surgery as they may increase the risk of surgical site infection. (IE).
2. In orthopedic and cardiac surgical procedures where adhesive incise drapes are used, consider using an iodophor-impregnated incise drape, unless the patient has an iodine allergy or other contraindication. (IIB).
Careful evaluation of wound protectors needs to be done before introducing the use of wound protectors as a routine measure to reduce SSI. (IIIC)
Do not apply vancomycin powder into the surgical site for prevention of surgical site infection, including spine surgery. (IC)
Laminar air flow
Installation of laminar airflow is not required in new or renovated operating rooms to prevent SSIs. (IIC)
Recommendations for post-operative wound management
Primary vacuum dressings or Negative Pressure Wound Therapy (i.e. for clean-contaminated and contaminated surgeries) and silver-based dressings have mixed results and individualized decisions on their use are suggested. Routine use for prevention of SSI is not recommended. (IIC)
We recommend hospitals in the Asia Pacific region that have high surgical site infection rates to consider reviewing their practices in accordance with the Guidelines for the Prevention of Surgical Site Infections to identify areas for improvement. We have chosen not to identify variables for a bundle. Instead, a gap analysis is recommended comparing current practices with the various recommendations in the guidelines. This should then be followed by a process improvement plan using the approach described in the APSIC Guide for Prevention of Central Line Associated Bloodstream Infections (CLABSI) to close the gaps identified .
Further studies are needed to demonstrate cost-effectiveness of prevention of SSIs using the process improvement approach, especially in a resource constrained setting.
We acknowledge support through an educational grant from 3 M Asia Pacific. APSIC acknowledges the help of Dr. Robert G. Sawyer, Professor of Surgery and Medical Engineering Chair, Department of Surgery Western Michigan University Homer Stryker MD School of Medicine; and Dr. Steven M. Gordon, Chairman, Department of Infectious Disease, Professor of Medicine, Cleveland Clinic for reviewing the document and giving their valuable comments and feedback.
Association Infection Prevention Control Nurse Indonesia
Chinese Society for Infection Control Sector, Chinese Preventive Medicine Association, China
Ho Chi Minh City Infection Control Society (HICS)
Hong Kong Infection Control Nurses Association (HKICNA)
Infection Control Society of Taiwan (ICST)
Infection Control Association of Singapore (ICAS)
Indonesian Society of Infection Control (INASIC)
National Nosocomial Infection Control Group of Thailand
Persatuan Kawalan Infeksi dan Antimikrobial Kota Kinabalu Sabah (PKIAKKS), Borneo
Korean Surgical Infections Society, South Korea
AA reviewed and authored the topics of pre-operative baths, MRSA screening and decolonization, and surgical skin preparation, surgical prophylaxis. AW reviewed and authored the topics of epidemiology, antimicrobial impregnated sutures and post-operative wound management. AzA reviewed and authored the topic of glycemic control. HYL reviewed and authored the topics of risk factors for SSI, mechanical bowel preparation and oral antibiotics for elective colorectal surgery, and oxygenation. KM reviewed and authored the topics of surveillance of surgical site infections, normothermia, normovolemia and hair removal. KY reviewed and authored the topics of irrigation, drapes and laminar airflow. MLL is the lead author of this manuscript and chaired the workgroup discussion. She also reviewed and authored the topics on surgical hand preparation, nutrition and wound protector. Both AzA and KY reviewed and authored the topics of vancomycin powder. All authors read and approved the final manuscript.
We acknowledge support through an educational grant from 3 M Asia Pacific in the development of the guidelines. 3 M is not involved in providing input to the guidelines. The guidelines were strictly developed with input from the authors.
Ethics approval and consent to participate
Consent for publication
The authors declare that they have no competing interests.
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