APPROACH TO

CURRENT GUIDELINES
OF SSI PREVENTION

HARI PARATON dr. SpOGK

KPRA-KEMENKES RI
WHO; Global Action Plan

1. Improve awareness and understanding of antimicrobial resist

ance through effective communication, education and training
2. Strengthen the knowledge and evidence base through surveillanc
e and research.
3. Reduce the incidence of infection through effective sanitati
on, hygiene and infection prevention measures.
4. Optimize the use of antimicrobial medicines in human and
animal health.
5. Develop the economic case for sustainable investment that takes
account of
the needs of all countries, and increase investment in new
medicines, diagnostic tools, vaccines and other interventions.
KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA KEMENTRIAN KESEHATAN
 AMR - ESBL

PREVALENCE of ESBL in INDONESIA 2002-2016

70
60 60
50 surveillan
ce 2016
presentage

50-82%
40 40
35
30 WHO/ ESBL
28 PPRA
RSDS 26-
20 RSDS 56%
10 9 AMRI
0
N
2000 2005 2010 2013 2016
MDRO - SSI
 The Incidence of SSI
• The incidence of SSI in Low Middle Income Country →
11.8 per 100 surgical procedures (range 1.2 to 23.6)

High income Countries ECDC. 2011 %

colon surgery 9,5
coronary artery bypass graft 3,5
caesarean section 2,9
cholecystectomy 1,4
hip prosthesis, 1.0
laminectomy 0,8
knee prosthesis 0,75
(WHO, 2011)
PATHOGEN RELATED ON SSI

Pathogen bacteria Resistance Antibiotic

E coli
• Extended
Klebsiella pneumonia spectrum
Pseudomonas A Cephalosphorin
MRSA • Carbapenem
Enterobactereceae • Fluoroquinolone
• Vancomycin
Acinetobacter
baumanii
 Risk Factor of SSI
(Patient characteristics)
 Risk Factor of SSI
Risk Factor ( Operation characteristics)

Surgical prophylaxis. SIGN 2014.

 What Can We Do?

How to Minimize SSI incidence

• Risk and Procedure control
• To optimize use of antibiotic

(WHO, 2015)
SURGICAL SITE INFECTION
PREVENTION
PRE OPERATIVE
 PRE OPERATIVE BATHING

QUALITY OF
RECOMENDATION STRENGHT
EVIDENCE

Conditional Moderate
There is good clinical practice for
patients to bathe or shower prior
to surgery.
• plain soap or an antimicrobial
soap
• The panel decided not to
formulate a recommendation on
the use of CHG- impregnated
cloths
 DECOLONIZATION
QUALITY OF
RECOMENDATION STRENGHT
EVIDENCE
• Patients undergoing cardiothoracic and Strong Moderate
orthopaedic surgery with known nasal
carriage of S. aureus should receive
perioperative intranasal applications of
mupirocin 2% ointment with or without a
combination of CHG body wash.

• The panel suggests considering to treat also

patients with known nasal carriage of S. Conditional Moderate
aureus undergoing other types of surgery
with perioperative intranasal applications of
mupirocin 2% ointment with or without a
combination of CHG body wash.
 SCREENING OF ESBL COLONIZATION
AND THE IMPACT ON ANTIBIOTIC PROPHYLAXIS

STRENGH QUALITY OF
RECOMENDATION
T EVIDENCE
The panel decided not to NA NA
formulate a recommendation
due to the lack of evidence.
 OPTIMAL TIMING FOR PREOPERATIVE
ANTIBIOTIC PROPHYLAXIS
QUALITY
STREN
RECOMENDATION OF
GHT
EVIDENCE
• SAP should be administered prior to the Strong Low
surgical incision

• The panel recommends the

administration of SAP within 120 minutes
before incision, while considering the Strong Moderate
half-life of the antibiotic
(fluroquinolone/vancomycine)

• optimal timing: 30-60 minutes prior incision /cephalosporin

Timing of SAP
 MECHANICAL BOWEL PREPARATION AND
THE USE OF ORAL ANTIBIOTICS

QUALITY
RECOMENDATION STRENGHT OF
EVIDENCE
preoperative oral antibiotics combined with Conditional Moderate
mechanical bowel preparation should be used
to reduce the risk of SSI in adult patients
undergoing elective colorectal surgery.

mechanical bowel preparation alone (without

administration of oral antibiotics) should not
be used for the purpose of reducing SSI in
adult patients undergoing elective colorectal Strong Moderate
surgery.
 HAIR REMOVAL

QUALITY
STRENGH
RECOMENDATION T OF
EVIDENCE
• patients undergoing any surgical Strong Moderate
procedure, hair should either not
be removed or,
• if absolutely necessary, it should be
removed only with a clipper.
Shaving is strongly discouraged at
all times, whether preoperatively or
in the OR.
 SURGICAL SITE PREPARATION
QUALITY
RECOMENDATION STRENGHT OF
EVIDENCE
Recommends alcohol-based Strong Low to
antiseptic solutions based on CHG moderate
for surgical site skin preparation in
patients undergoing surgical
procedures.
 ANTIMICROBIAL SKIN SEALANTS

QUALITY OF
RECOMENDATION STRENGHT
EVIDENCE
Antimicrobial sealants Conditional Very Low
should not be used after
surgical site skin
preparation for the purpose
of reducing SSI.
 SURGICAL HAND PREPARATION

QUALITY OF
RECOMENDATION STRENGHT
EVIDENCE

Surgical hand preparation should Strong Moderate

be performed by scrubbing with
either a suitable antimicrobial
soap and water or using a suitable
alcohol-based hands rub before
donning sterile gloves.
Comparative antimicrobial efficacy of alcohol-based hand rub
and conventional surgical scrub in a medical center
Ni-Jiin Shen et al 2015

Journal of Microbiology, Immunology and Infection (2015) 48, 322e328

PERIOPERATIVE DISCONTINUATION OF
IMMUNOSUPPRESSIVE AGENT

QUALITY OF
RECOMENDATION STRENGHT
EVIDENCE
suggests not to Conditional Very Low
discontinue
immunosuppressive
medication prior to surgery
for the purpose of
preventing SSI.
 PERIOPERATIVE OXYGENATION

QUALITY
OF
RECOMENDATION STRENGHT
EVIDENC
E
For adult patients undergoing general Strong Moderate
anaesthesia with endotracheal intubation for
surgical procedures should receive an 80%
fraction of inspired oxygen intraoperatively
and, if feasible, in the immediate
postoperative period for 2-6 hours to reduce
the risk of SSI.
 WARM CONDITION

QUALITY
RECOMENDATION STRENGHT OF
EVIDENCE

The panel suggests the use of Conditional Moderate

warming devices in the OR
and during the surgical
procedure for patient body
warming with the purpose of
reducing SSI
 MAINTENANCE OF ADEQUATE
CIRCULATING VOLUME CONTROL/
NORMOVOLEMIA

QUALITY OF
RECOMENDATION STRENGHT
EVIDENCE

The panel suggests the use of Conditional Low

goal-directed fluid therapy
intraoperatively to reduce the
risk of SSI.
 DRAPES AND GOWNS

QUALITY OF
RECOMENDATION STRENGHT
EVIDENCE
• suggests that either sterile, disposable Conditiona moderate to
non-woven or sterile, reusable woven l very low
drapes and gowns can be used during
surgical operations for the purpose of
preventing SSI.

• suggests not to use plastic adhesive

incise drapes with or without
antimicrobial properties for the purpose
of preventing SSI.
 WOUND PROTECTOR DEVICES

RECOMENDATION STRENGHT QE

suggests considering the use of Conditional very

wound protector devices in low
clean-contaminated,
contaminated and dirty
abdominal surgical procedures
for the purpose of reducing the
rate of SSI.
 INCISIONAL WOUND IRRIGATION

QUALITY
RECOMENDATION STRENGH
OF EVIDENCE
• The panel considered that there is NA NA
insufficient evidence to recommend
for or against saline irrigation of
incisional wounds before closure for
the purpose of preventing SSI.
Conditional VERY LOW
• The panel suggests that antibiotic
incisional wound irrigation should not
be used for the purpose of preventing
SSI.
 USE OF DOUBLE SURGICAL GLOVES

QUALITY OF
RECOMENDATION STRENGHT
EVIDENCE
The panel decided not to formulate a NA NA
recommendation due to the lack of
evidence to assess whether double-
gloving or a change of gloves during
the operation or the use of specific
types of gloves are more effective in
reducing the risk of SSI.
 ANTIMICROBIAL -COATED SUTURES

QUALITY OF
RECOMENDATION STRENGHT
EVIDENCE
CONDITIONAL MODERATE
The panel suggests the use of
triclosan-coated sutures for
the purpose of reducing the
risk of SSI, independent of the
type of surgery.
 RE-DOSING

QUALITY OF
RECOMENDATION STRENGHT
EVIDENCE
Redosing intervals:

• Cefazolin, every 3 or 4 hours

• Clindamycin, every 4 or 6 hours
• Vancomycin, no redosing or every 6
hours.
POST OPERATIVE
 ANTIBIOTIC PROLONGATION

QUALITY OF
RECOMENDATION STRENGHT
EVIDENCE
STRONG MODERATE
The panel recommends against
the prolongation of SAP after
completion of the operation for
the purpose of preventing SSI.
 PROPHYLACTIC NEGATIVE PRESSURE
WOUND THERAPY

QUALITY OF
RECOMENDATION STRENGHT
EVIDENCE
The panel suggests the use of CONDITIO LOW
prophylactic negative pressure NAL
wound therapy in adult patients
on primarily closed surgical
incisions in high-risk wounds for
the purpose of the prevention of
SSI, while taking resources into
account.
ANTIMICROBIAL PROPHYLAXIS IN THE PRESENCE
OF A DRAIN AND OPTIMAL TIMING FOR WOUND
DRAIN REMOVAL

QUALITY OF
RECOMENDATION STRENGHT
EVIDENCE
CONDITIONAL LOW
preoperative antibiotic prophylaxis should
not be continued in the presence of
a wound drain for the purpose of preventing
SSI.
CONDITIONAL VERY LOW
The panel suggests removing the wound
drain when clinically indicated. No evidence
was found to allow making a
recommendation on the optimal timing of
wound drain removal for the purpose of
preventing SSI.
 ADVANCED DRESSINGS

QUALITY OF
RECOMENDATION STRENGHT
EVIDENCE

The panel suggests not using CONDITIONAL LOW

any type of advanced dressing

over a standard dressing on
primarily closed surgical
wounds for the purpose of
preventing SSI.
 THANK YOU

PRUDENT USE OF ANTIBIOTIC