Il Giornale di Chirurgia

Surgical Perspectives Journal of the Italian Surgical Association

OPEN

ACOI Surgical Site Infections Management

Academy (ACOISSIMA)
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Recommendations on the prevention of surgical site infections

Massimo Sartellia*, Francesco Corteseb, Marco Scatizzic, Francesco Maria Labricciosad, Stefano Bartolie,
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Francesco Nardacchionef, Gabriele Sgangag, Nicola Cillarah, Gianluigi Luridianai, Rita Murrij, Mario Camplik,

Marco Catarcil, Felice Borghim, Francesco Di Marzon, Walter Siquinia, Fausto Catenao, Federico Coccolinip,
Mariano Fortunato Armellinoq, Gianandrea Baldazzir, Massimo Bastis, Giovanni Ciacciot, Vincenzo Bottinou, Pierluigi Mariniv

Background: Surgical site infections (SSIs) are the most common cause of healthcare-associated infections in surgical patients.
Many SSIs may be preventable if simple measures are respected. Despite evidence supporting the effectiveness of evidence-
based practices in Infection Prevention and Control, many surgeons fail to implement them.
Methods: To clarify the key issues in the prevention of SSIs, an expert panel designated by the board of directors of Associazione Chirurghi
Ospedalieri Italiani—Italian Surgical Association (ACOI) convened in Rome, Italy, on 16 December 2021, for a consensus conference.
Results: The expert panel approved 11 evidence-based statements regarding the prevention of SSIs. A article was drafted and
reviewed by the expert panel, finally obtaining this document that represents the executive summary of the consensus.
Conclusions: The document aims to disseminate best practices among Italian surgeons and summarizes the ACOI
recommendations for the prevention of SSIs.
Keywords: Antimicrobial resistance; Healthcare-associated infections; Infection prevention and control; Surgical antibiotic
­prophylaxis; Surgical site infections

a
General and Emergency Surgery Unit, Macerata Hospital, Macerata, Italy; bEmergency
Surgery Unit, San Filippo Neri Hospital, Roma, Italy; cGeneral Surgery Unit, Santa Maria
Annunziata Hospital, Firenze, Italy; dGlobal Alliance for Infections in Surgery, General
Secretary, Macerata, Italy; eVascular Surgery Unit, S. Eugenio Hospital, Roma, Italy;
f
ACOI, General Secretary, Roma, Italy; gDepartment of Medical and Surgical Sciences,
Emergency Surgery & Trauma, Fondazione Policlinico Universitario A. Gemelli IRCCS,
Roma, Italy; hGeneral Surgery Unit, Santissima Trinità Hospital, Cagliari, Italy; iOncologic
and Breast Surgical Unit, Armando Businco Oncology Hospital, Cagliari, Italy;
j
Department of Laboratory and Infectious Diseases Sciences, Infectious Diseases Unit,
Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; kACOI, Secretary,
Roma, Italy; lGeneral Surgery Unit, Sandro Pertini Hospital, Roma, Italy; mOncologic
Surgery Unit, Candiolo Cancer Institute FPO - IRCCS, Torino, Italy; nGeneral and
Emergency Surgery Unit, New Apuan Hospital, Massa-Carrara, Italy; oEmergency
Surgery Unit, “Bufalini” Hospital, Cesena, Italy; pGeneral, Emergency and Trauma
Surgery Unit, Pisa University Hospital, Pisa, Italy; qGeneral and Emergency Surgery
Unit, Salerno Hospital, Salerno, Italy; rGeneral Surgery Unit, ASST Nord Hospital, Sesto
San Giovanni, MI, Italy; sGeneral and Emergency Surgery Unit, St Spirito’s Hospital
of Pescara, Pescara, Italy; tGeneral and Emergency Surgery Unit. Sant’Elia Hospital,
Caltanissetta, Italy; uGeneral Surgery Unit, “Villa Betania” Hospital, Napoli, Italy; and
v
General and Emergency Surgery Unit, S. Camillo-Forlanini Hospital, Roma, Italy.
The authors declare that they have no conflicts of interest with regard to the
content of this report.
All author participated in the writing of the article.
*Corresponding Author. Address: General and Emergency Unit, Macerata
Hospital, Macerata, Italy. E-mail: massimosartelli@gmail.com (M. Sartelli).
Copyright © 2022 The Authors. Published on behalf of the Associazione Chirurghi
Ospedalieri Italiani and Wolters Kluwer. This is an open access article distributed
under the Creative Commons Attribution License 4.0 (CCBY), which permits
unrestricted use, distribution, and reproduction in any medium, provided the
original work is properly cited.
Journal of the Italian Surgical Association (2022) 42:2
Received: 26 April 2022; Accepted 24 June 2022
Published online 10 August 2022
DOI: 10.1097/IA9.0000000000000002
Introduction
Antimicrobial resistance (AMR) has recently emerged as one
of the most serious public health issues of the 21st century.
Despite the multifaceted nature of AMR affecting humans, ani-
mals and the environment, healthcare workers play a critical
role in containing the spread of AMR.
In a study published in 2019, Cassini et al1 examined the
weight of infections caused by multidrug-resistant bacteria
(MDRB) in invasive isolates in Europe. Processing the 2015 data
of the European Antimicrobial Resistance Surveillance Network
(EARS-Net), the authors published the first estimate of the impact
of AMR on the European population. They estimated 671,689
infections with MDRB, of which 63.5% were healthcare-asso-
ciated infections (HAIs). The infections caused by MDRB had
the potential to cause 33,110 attributable deaths each year in
Europe (equal to the sum of deaths caused by influenza, AIDS,
and tuberculosis) and 874,541 disability-adjusted life-years. The
study demonstrated that Italy and Greece had the most infections
caused by MDRB in Europe. Although the Italian population is
of a medium-high age, it is notable that about a third of deaths
due to MDRB infections in Europe had been in Italy.
To tackle the burden of AMR, the Italian Ministry of Health
in 2017 published the “National Antimicrobial Resistance
Contrast Plan (PNCAR) 2017–2020,”2 addressing the AMR
burden according to the general One Health strategy and
identifying strategies and actions to be implemented at differ-
ent levels: national, regional, and local. In 2020, the program
was extended to 2021 because of the COVID-19 pandemic and
will be updated with a new plan that will be valid for the years
2022–2025.
During the elaboration of the PNCAR, the Ministry of
Health invited the European Centre for Disease Prevention and
Control (ECDC) to plan a visit to Italy with a team of experts.

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 Sartelli et al. • Volume 42 • Number 2 • 2022
In December 2017, the ECDC published a report on the preven-
tion and control of AMR in Italy.3 The report summarized visits
and meetings that ECDC experts had in Italy to discuss and
specifically assess the situation regarding AMR in Italy. The visit
took place from 9 January 2017, to 13 January 2017, and, after
visiting three different regions, and some hospitals, speaking
with experts and representatives of the institutions, the ECDC
delegates wrote their conclusions. The experts highlighted the
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threat represented by the AMR, and the need for coordination
to address this phenomenon, so that the good practices already
consolidated in some areas of the country could become a com-
mon heritage in the daily practice of all healthcare workers in
Italy.
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According to a report by the Organization for Economic
Co-operation and Development (OECD),4 in Italy, the propor-
tion of antibiotic-resistant infections has grown from 17% in
2005 to 30% in 2015, and will reach 32% in 2030, if antibiotic
consumption continues to follow the same trends.
In Italy, since 2001, the Italian National Institute of Health5
has been coordinating the surveillance system of the sistema
nazionale di sorveglianza sentinella dell’antibiotico-resistenza
antibiotic resistance in the human sphere, consisting of a net-
work of hospital laboratories recruited voluntarily, with the
primary aim of describing the frequency and trend of AMR in
a selected group of bacteria isolated from infections of clinical
relevance (above all bacteremia), representing both commu-
nity-acquired infections and healthcare-associated infections
(Staphylococcus aureus, Enterococcus faecium and E. faecalis,
Klebsiella pneumoniae, Pseudomonas aeruginosa, Escherichia
coli, Acinetobacter baumannii).
The percentage of E. coli resistant to third-generation ceph-
alosporins was decreasing in 2020 (26.4%) compared with
2019 (30.8%), while a decreasing trend in the last 6 years
(2015–2020) was observed for aminoglycosides (from 18.4%
in 2015 to 15.2% in 2020), and fluoroquinolones (from
44.4% in 2015 to 37.6% in 2020). For the second consecu-
tive year, there was an increase in the percentage of isolates
of K. pneumoniae resistant to carbapenems (29.5% in 2020
vs. 28.5% in 2019), after a slight decline observed in previous
years. Resistance to carbapenems was confirmed to be very
low in E. coli (0.5%) but increased in P. aeruginosa (15.9%)
and in Acinetobacter spp. (80.8%). Among Gram-negative
bacteria, 33.1% of K. pneumoniae isolates and 10.0% of
E. coli isolates were found to be multiresistant (resistant to
third-generation cephalosporins, aminoglycosides, and fluo-
roquinolones). In 2020, both of these values were decreas-
ing compared with previous years. Regarding P. aeruginosa,
the percentage of resistance to three or more antibiotics
including piperacillin-tazobactam, ceftazidime, carbapenems,
aminoglycosides, and fluoroquinolones was 12.5%, also in
decrease compared with previous years, while a percentage
of multi-resistance (fluoroquinolones, aminoglycosides, and
carbapenems) was found very high (78.8%) and increasing
for Acinetobacter spp. Regarding S. aureus, the percentage of
methicillin-resistant isolates remained stable, around 34%,
while a worrying trend continued to increase in the percent-
age of E. faecium isolates resistant to vancomycin, which in
2020 was 23.6%.
One of the crucial aspects of combating AMR is the imple-
mentation of infection prevention and control (IPC) programs.
HAIs are infections occurring while patients receive healthcare,
and many of them are caused by MDRB. Patients with medi-
cal devices (central lines, urinary catheters, ventilators) or who
undergo surgical procedures are at risk of HAIs.
In Italy, there is no systematic national surveillance system for
HAIs, but a point prevalence surveillance study was conducted
during the period October 2016–November 2016: it included
56 facilities and selected 14,773 patients distributed in various
departments (medicine, surgery, intensive care, gynecology and
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obstetrics, pediatrics, rehabilitation, neonatology, geriatrics,
psychiatry, long-term care).6 The prevalence of patients with at
least one HAI was 8.03%.
The occurrence of HAIs such as surgical site infections
(SSIs), catheter-associated urinary tract infections (CAUTIs),
central line-associated bloodstream infections (CLABSIs), ven-
tilator-associated pneumonia (VAP), hospital-acquired pneu-
monia (HAP), and Clostridioides difficile infection continues
to escalate at an alarming rate. These infections result in sig-
nificant patient illnesses and deaths, prolong the duration of
hospital stays, and often necessitate additional diagnostic and
therapeutic interventions, generating added costs to those
already incurred by the patient’s underlying disease.7 However,
the perception of the phenomenon is not yet sufficiently high
among healthcare workers, resulting in a low level of adequate
responses.
Many SSIs may be preventable if simple rules are respected.
Both the World Health Organization (WHO),8–10 and the Centers
for Disease Control and Prevention (CDC)11 have published
guidelines for the prevention of SSIs. In 2016, the American
College of Surgeons and the Surgical Infection Society updated
their surgical site infection guidelines.12 In 2019, the National
Institute for Health and Care Excellence (NICE) updated its
guidelines for the management of SSIs.13
Despite all the published guidelines, knowledge and aware-
ness of IPC measures among surgeons are frequently insuffi-
cient, and there is a significant gap between the evidence-based
practice and clinical practice regarding to the prevention of
SSIs.
The WHO Global guidelines for the prevention of SSIs are
evidence-based, addressing the global burden of SSIs on both
patients and healthcare systems. They have been designed
to be suitable for any country and can be locally adapted,
including 13 recommendations for preventing infections
before surgery and 16 for preventing infections during and
after surgery.10
Classification and definition
SSIs are the most common cause of HAIs in surgical patients.
SSIs are generally classified according to universal criteria.14 SSIs
are divided into incisional and organ/space infections. Incisional
infections are further classified as superficial involving skin and
subcutaneous tissue, and deep involving deep soft tissue muscle
and fascia. Deep and organ/space infections represent the SSIs
causing the most morbidity.
To compare SSI rates between hospitals and avoid subjective
interpretation, an accurate standardization of the case defini-
tions is crucial. To reduce subjectivity and ensure standardiza-
tion of definitions across Europe, in 2017, ECDC published the
HAI-Net SSI protocol version 2.2.15
Superficial incisional infections are classified as infections
occurring within 30 days after the surgical procedure involving
only skin and subcutaneous tissue of the incision and at least
one of the following criteria:
• purulent drainage with or without laboratory confirmation,
• organisms isolated by an aseptically obtained culture of
fluid or tissue,
• at least one of the following signs or symptoms of infection
including pain or tenderness, localized swelling, redness, or
heat and the superficial incision is deliberately opened by a
surgeon (unless culture of incision is negative),
• diagnosis of superficial incisional SSI made by a surgeon or
a physician.
Deep incisional infections are classified as infections occur-
ring within 30 days after the surgical procedure if no implant
is left in place or within 90 days if implant is in place and the
infection appears to be related to the operation and infection
 Sartelli et al. • Volume 42 • Number 2 • 2022
involves deep soft tissue (e.g., fascia, muscle) of the incision and
at least one of the following criteria:
• purulent drainage from the deep incision,
• dehiscence or deliberate opening by the surgeon from
the deep incision when the patient has at least one of the
following signs or symptoms of clinical infection: fever
(> 38 °C), localized pain or tenderness, unless incision is
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culture-negative,
• an abscess or other evidence of infection involving the deep
incision is found on direct examination, during reopera-
tion, or by histopathologic or radiologic examination,
• diagnosis of deep incisional SSI made by a surgeon or
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attending physician.
Organ/space infections are classified as infections occurring
within 30 days after a surgical procedure involving any part
of the anatomy other than the incision and at least one of the
following criteria:
• purulent drainage from a drain that is placed through a
stab wound into the organ/space,
• organisms isolated from an aseptically obtained culture of
fluid or tissue in the organ/space,
• an abscess or other evidence of infection involving the
organ/space that is found on direct examination,
• during reoperation, or by histopathologic or radiologic
examination diagnosis of organ/space SSI made by a sur-
geon or attending physician.
Methods
The Italian surgical societies are becoming more conscious of the
importance of preventing HAIs across the surgical pathway. In
particular, Associazione Chirurghi Ospedalieri Italiani—Italian
Surgical Association (ACOI) has included the prevention of SSIs
in its training program, setting up a multidisciplinary task force
and organizing a series of educational events (ACOI Surgical
Site Infections Management Academy [ACOISSIMA]) through-
out the whole national territory in order to increase knowledge
and awareness on the prevention of SSIs among Italian sur-
geons. Following expert interventions, each event included the
active participation of local surgeons to assess the state-of-the-
art in the prevention of SSIs and AMR in various Italian regions.
In order to investigate the awareness of Italian surgeons
about the prevention of SSIs, in June 2021, ACOI conducted
an anonymous survey addressed to all members. An electronic
invitation with a link to the survey was sent to about 3,200
members of ACOI by the weekly newsletter. The survey was
Internet-based. Participation was voluntary and anonymous.
No incentives were provided to the respondents.
The 15-item self-administered questionnaire collected infor-
mation about the behavior of Italian surgeons in preventing and
treating infections across the surgical pathway.
Among the 3,200 surgeons contacted by email, 371 (11.6%)
completed the survey. The overall participation was low, disclos-
ing poor awareness of the problem.
To clarify the key issues in the prevention of SSIs across
the surgical pathway, an expert panel designated by the ACOI
Board of Directors convened in Rome, Italy, on 16 December
2021, for a consensus conference. The panelists approved 11
evidence-based statements developed for topic questions regard-
ing the prevention of SSIs, aiming to define quality indicators
statements to be respected in every Italian surgical unit. To
design the statements, a literature search, using the PubMed
database, was performed without restriction of time or type of
article. The search was limited to English-language publications.
The expert panel drafted and reviewed a article, finally
obtaining this document that represents the executive summary
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of the consensus. It summarizes the ACOI recommendations for
SSIs prevention.
The present recommendations were developed according
to the grading of recommendations assessment, development
and evaluation methodology.16,17 The quality of evidence was
marked as high, moderate, low, or very low. The strength of
the recommendation was qualified as weak or strong based on
the agreement of the expert panel (>80%). The following set of
recommendations aims to reinforce best practices among Italian
surgeons.
Statement 1
As many HAIs may be preventable, each surgical department
should have in place and implement measures aimed at reducing
the risk of HAIs including SSIs, before, during, and after surgery.
Multidisciplinary educational projects should be implemented
aiming to increase knowledge and raise awareness and account-
ability (Moderate quality of evidence, strong recommendation).
SSIs are the most common HAIs in surgical departments. The
prevention of SSIs should be a priority for all surgical depart-
ments worldwide. Bacteria are becoming increasingly resistant
to antibiotics, making the prevention of SSIs more import-
ant nowadays. SSIs are associated with longer postoperative
hospital stays and result in higher attributable morbidity and
mortality.12
Safe surgical care requires a range of precautions aimed at
reducing the risk of SSIs before, during, and after surgery. Many
SSIs may be preventable if simple rules are respected. In 2018,
a systematic review and meta-analysis of studies between 2005
and 2016 evaluated the results of multifaceted interventions to
prevent CAUTIs, CLABSIs, SSIs, and VAP/HAP in acute care or
long-term care settings. Published evidence suggests a poten-
tial reduction of HAI rates in the range of 35%–55% associ-
ated with multifaceted interventions irrespective of a country’s
income level.18
Another systematic review of the interventions to reduce
HAIs demonstrated that 65%–70% of cases of CLABSIs and
CAUTIs and 55% of cases of VAP and SSIs could be prevent-
able with evidence-based strategies. The authors concluded
that 100% prevention of HAIs could not be attainable with
evidence-based prevention strategies; however, comprehensive
implementation of such strategies could prevent many HAIs and
save lives, reducing costs.19
Teamwork is crucial for achieving a comprehensive
approach to providing care that is adequate to optimize both
individual health outcomes and overall service delivery of
healthcare. Effective teamwork can have a positive impact
on patient safety. Healthcare teams that communicate effec-
tively result in enhanced patient safety and improved clinical
performance.
The IPC teams aim to prevent the acquisition and dissem-
ination of HAIs within healthcare facilities. Many hospital
professionals are typically involved in IPC teams, making col-
laboration essential.20 The multidisciplinary approach reinforces
the concept that professionals bring with them their particular
expertise and are responsible for their respective contributions
to patient care. In this context, the direct involvement of sur-
geons may be important.
All surgeons should have the necessary knowledge to
respect effective IPC practices. Increasing knowledge may
influence their perceptions and motivate them to change
behavior.
In 2018, the WHO published a document to support the pre-
vention of SSIs around the world.21 The purpose of the doc-
ument is to present a range of approaches to achieve, in the
context of a broader surgical safety climate, successful imple-
mentation of SSIs prevention at a facility level.
 Sartelli et al. • Volume 42 • Number 2 • 2022
Knowledge is fundamental for effective IPC.22 Lack of knowl-
edge about the appropriateness, efficacy, and use of prevention
measures determine poor compliance. To overcome these barri-
ers, education and training are the cornerstones of improvement
in prevention practices.
Education of surgeons in preventing HAIs should begin at
the undergraduate level and should be consolidated with further
training throughout the postgraduate years. Surgical societies
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may have a crucial role in educating surgeons about IPC pro-
grams. Efforts to improve educational programs are required,
and it is necessary that in Italy, appropriate educational pro-
grams will be further reinforced to drive surgeons towards cor-
rect behaviors in the prevention of HAIs.
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Finally, adequate IPC strategies depend on both healthcare
workers’ behaviors and the organizational characteristics of
acute healthcare facilities that can promote a behavioral change.
Accountability is an essential aspect in preventing HAIs.23
Without accountability, evidence-based strategies cannot be
implemented, and are used in a fragmented way, decreasing their
effectiveness. Accountability begins with the hospital executive
officer and other leaders supporting the imperative for a culture
of patient safety, making the prevention of HAIs an organiza-
tional priority.
Statement 2
Facility-based surveillance of HAIs, including SSIs, surveillance
should be performed to guide interventions with timely feed-
back of results to surgeons.
Every surgical unit should know the effectiveness of the
adopted prevention strategies (Low quality of evidence, strong
recommendation).
Surveillance includes monitoring of an event, collection and
analysis of the data associated with the event, and timely feed-
back to healthcare workers who can implement evidence-based
strategies to improve patients’ outcomes by decreasing the inci-
dence of the event.24 Surveillance allows hospitals and clinicians
to measure the effectiveness of strategies that are implemented
to decrease infection rates.25
The surveillance of SSIs is one of the most important com-
ponents of an effective IPC program and has been shown to
be crucial to reduce the risk of SSIs.26,27 Hospitals should per-
form surveillance for SSIs to identify trends in infection rates,
improve infection prevention practices and decrease the inci-
dence and the burden of these costly and common hospital-ac-
quired infections.
An ideal surveillance system should routinely audit and pro-
vide confidential feedback on SSI rates and adherence to pre-
vention measures to individual surgeons, the surgical division
and/or department chiefs, and hospital leadership.28 However,
systematic surveillance of SSIs is challenging and requires exper-
tise and resources because active surveillance is a resource- and
time-consuming activity.
In Italy, continuous surveillance of SSIs is routinely per-
formed by only a few regions, and the real impact of SSIs
in the country is not known, making impossible to assess
the quality of healthcare in preventing and controlling SSIs.
Data on nonprosthetic surgery from an Italian surveillance
program of SSIs for the period 2009 to 201129 demonstrated
that implementation of a national surveillance program was
helpful in reducing SSI rates and should be prioritized in all
healthcare systems.
Recently the ECDC published the Annual Epidemiological
Report,30 sharing data collected in 2017 in hospitals participat-
ing in national or regional surveillance of SSIs across Europe.
The SSI surveillance protocol included the following nine
surgical procedures: coronary artery bypass graft, open and
laparoscopic cholecystectomy, open and laparoscopic colon
surgery, cesarean section, hip prosthesis, knee prosthesis, and
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laminectomy. The standardized follow-up period was 31 days
except for deep or organ/space infections following orthopedic
operations with an implant in place. For these surgical proce-
dures, the follow-up period was extended to 91 days. In 2017,
10,149 SSIs were reported. Of these, 4,739 (46.7%) were super-
ficial, 3,088 (30.4%) deep, and 2,274 (22.4%) organ/space SSIs.
In 48 (0.5%) SSIs, the type of SSI was unknown. The percentage
of SSIs varied greatly, from 0.5% in knee prosthesis operations
to 10.1% in open colon surgery operations. Both in cholecys-
tectomy and colon resections, the percentage of SSIs was lower
in laparoscopic procedures than in open procedures. S. aureus
(21.5%) and E. coli (13.9%) were the most isolated bacteria.
For cholecystectomy and colon resections, the most frequently
reported bacteria were Enterobacterales. For all other types of
surgical procedures, Gram-positive cocci were the most isolated
bacteria.
Statement 3
An approved local protocol of surgical antibiotic prophylaxis
(SAP) according to the local microbiological epidemiology
should be in place in each surgical unit. Its appropriate appli-
cation should be periodically verified (Low quality of evidence,
strong recommendation).
Surgical antibiotic prophylaxis (SAP) is one of the most
important perioperative measures for preventing SSIs. SAP
aims to achieve serum and tissue antibiotic levels exceeding the
antibiotic’s minimum inhibitory concentration for the duration
of the surgical procedure. It allows to counteract the prolifer-
ation of bacteria likely to be encountered during the surgical
procedure.
Approximately 15% of all antibiotics in hospitals are pre-
scribed for SAP.31,32 Inadequate SAP prescriptions can be a major
driver of “opportunistic” infections such as C. difficile, select
MDRB and increase healthcare costs.33,34
Although the principles of SAP are clearly established and
guidelines have been published, implementing these guide-
lines is problematic among surgeons. In 2013, the American
Society of Health-System Pharmacists (ASHP), the Infectious
Diseases Society of America (IDSA), the Surgical Infection
Society (SIS), and the Society for Healthcare Epidemiology of
America (SHEA) published a set of clinical practice guidelines
for SAP.35
Prolonged administration of antibiotics in the postoperative
period is the most common reason for inappropriate SAP.36 An
Italian study evaluating the appropriateness of the prescription
of SAP demonstrated that only 18.1% of the patients received
appropriate SAP.37 A British study described how antibiotic
prescription was considered by surgeons as a secondary task,38
while other studies underlined the lack of motivation and time
to develop nonsurgical skills among surgeons.39
To define the association of type and duration of SAP with
SSIs, acute kidney injury (AKI), and C. difficile infection, a mul-
ticenter, national retrospective cohort study was published in
2019.40 Increasing duration of SAP was associated with a higher
risk of AKI and C. difficile infection; extended duration did not
lead to additional reduction of SSIs.
One way to engage surgeons may be to adapt guidelines into
a local protocol defining responsibilities for actions among a
multidisciplinary team. Moreover, since the choice of SAP also
depends on local epidemiology, a local adaptation of guidelines
for SAP should be developed and implemented in each surgi-
cal unit. Guidelines for perioperative antibiotic prophylaxis in
adults were updated in 2011 by the Italian Institute of Health.41
Local protocols should integrate the statement of these guide-
lines into a local protocol. Several studies demonstrated that
implementation of a SAP program including the creation of a
local protocol, the organization of educational sessions, and
planning periodic revision of prescriptions was effective in
 Sartelli et al. • Volume 42 • Number 2 • 2022
reducing antibiotic consumption, antibiotic prophylaxis cost,
and the incidence of SSIs.42,43
However, other studies revealed that implementation of inter-
ventions led to improved quality of SAP administration as well
as a reduction in antibiotic use and cost without a significant
reduction in SSIs.44,45 van Kasteren et al45 in a prospective study
of elective surgical procedures in 13 Dutch hospitals, evaluated
the quality of SAP before and after an intervention consisting
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of performance feedback and implementation of national clini-
cal practice guidelines. Antibiotic use decreased from 121 to 79
DDD/100 procedures, and costs were reduced by 25% per pro-
cedure. After the intervention, the antibiotic choice was inappro-
priate in only 37.5% of the cases instead of 93.5% of expected
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cases in the absence of any intervention. Prolonged prophylaxis
was observed in 31.4% instead of 46.8% of expected cases and
inappropriate timing in 39.4% instead of the expected 51.8%.
Time series analysis showed that all improvements were statis-
tically significant (P < 0.01). The overall SSI rates before and
after the intervention were 5.4% (95% confidence interval [CI]
= 4.3%, 6.5%) and 4.6% (95% CI = 3.6%, 5.4%), respectively.
To evaluate the impact of an educational, participative and
continuing antimicrobial stewardship program on prescription
adherence, a study was conducted between 2013 and 2019 on
an Italian University Hospital performing more than 40.000
surgical interventions per year.46 Data about SAP were collected
from two separate surveys, one at baseline (April 2013) and
one after the long-term antimicrobial stewardship intervention
(post-intervention, April 2019). Overall, guidelines adherence
improved from 36.6% (n = 149) at baseline to 57.9% (n =
221) post-intervention (P < 0.0001). A significant improvement
(P < 0.001) was also detected for each category: indication
(from 58.5% to 93.2%), selection and dosing (from 58.5% to
80.6%), timing (from 92.4% to 97.6%), duration (from 71%
to 80.1%).
Statement 4
Due to their demonstrated efficacy, optimizing patients’ physio-
logic function by enhanced recovery after surgery (ERAS) pro-
tocols and limiting perioperative blood transfusions by patient
blood management (PBM) protocols should be implemented to
improve the patient’s response to infections (Low quality of evi-
dence, strong recommendation).
Enhanced recovery after surgery (ERAS) programs are evi-
dence-based pathways designed to optimize the perioperative
care of surgical patients before, during, and after surgery.47 ERAS
Societyconsensus guidelines are powerful tools implemented
worldwide across hospitals in order to improve the quality of
surgical care 47 and Italian surgical societies such as ACOI and
PeriOperative Italian Society (POIS) have already reached a con-
sensus for their implementation in colorectal surgery.48
The basic principles of ERAS include attention:
• to preoperative measures including preoperative counseling
and nutritional strategies;
• to perioperative measures including regional anesthetic
and nonopioid analgesic approaches, fluid balance, main-
tenance of normothermia; and
• to postoperative measures including postoperative recovery
strategies, including early mobilization, early removal of
the urinary catheter and appropriate thromboprophylaxis.
Patient blood management (PBM) is an evidence-based
approach aiming to optimize patient outcomes by clinically
managing and preserving a patient’s own blood.49 PBM aims
to detect and treat anemia, minimize the risk of blood loss and
the need for transfusions for each patient through a coordinated
multidisciplinary process of care. The three pillars of PBM are
the following:
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• • diagnosing and treating anemia (especially iron deficiency
anemia),
• • minimizing blood loss, and
• • avoiding unnecessary transfusions.50
Several studies described the correlation between perioper-
ative blood transfusion and increased SSIs in both general sur-
gery51,52 and colorectal surgery.53,54
A large population-based retrospective study in Western
Australia clearly showed a 21% reduction of HAIs after PBM
implementation.55
A meta-analysis and systematic review about the impact of
ERAS and fast-track surgery for abdominal or pelvic surgery on
HAIs was published in 2017. The results suggested that ERAS
protocols were powerful tools to prevent three of the major
HAIs, including HAP, CAUTI, and SSIs.56 The role of ERAS in
decreasing SSIs has been debated. With the expansion of laparo-
scopic interventions, ERAS has increasingly incorporated lapa-
roscopic patients, especially in colorectal surgery. Laparoscopic
colonic surgery was associated with a lower rate of SSIs in sev-
eral studies,57,58 and the combination of laparoscopy and ERAS
protocols might be even more beneficial.
Some studies reported that ERAS in colorectal surgery was
associated with a reduction in the occurrence of SSIs.59,60 In
other studies, it was not possible to demonstrate a benefit of
ERAS compliance on SSIs incidence, while laparoscopic surgery
was clearly protective.61
The expert panel suggests that ERAS, PBM and IPC are
important patient safety interventions that can improve patients’
response to infections.
Statement 5
Hand hygiene is the cornerstone of IPC. When optimally per-
formed, hand hygiene reduces HAIs and the spread of anti-
microbial resistance. Correct hand hygiene should always be
performed during the surgical pathway. Its appropriateness and
the consumption of alcohol-based hand rub used by surgeons
should be monitored periodically (Moderate quality of evi-
dence, strong recommendation).
Hand hygiene is an important indicator of patients’ safety
and quality of care delivered in all healthcare settings, includ-
ing surgical departments. The purpose of routine hand hygiene
in patient care is to remove dirt and organic material and
reduce microbial contamination from transient microbiolog-
ical flora.
The objective of cleaning hands and forearms prior to surgery
is to reduce the bacteria on the skin. Surgical hand preparation
is crucial to maintain the lowest possible contamination of the
surgical field, especially in the event of sterile glove puncture
during the procedure.12
The 2016 WHO guidelines for the prevention of SSIs recom-
mend to perform surgical hand preparation either by scrubbing
with a suitable antimicrobial soap and water or using a suitable
alcohol-based hand rub solution before donning sterile gloves.
The statement is supported by moderate quality of evidence.
The meta-analysis conducted by WHO experts included 64
studies. However, among these studies, there were only six stud-
ies with SSIs as primary outcome, including three randomized
control trials, three observational studies, and two comparative
cohorts.62
Surgical hand preparation should be performed either by
scrubbing with an adequate antimicrobial soap and water or
an adequate alcohol-based hand rub solutions containing 60%–
80% alcohol before donning sterile gown and gloves.63
Hand hygiene in healthcare can be monitored directly or indi-
rectly. Direct methods to monitor hand hygiene in healthcare
include direct observation, patient assessment, or healthcare
workers’ self-reporting. Indirect methods include monitoring
 Sartelli et al. • Volume 42 • Number 2 • 2022
the consumption of products, such as soap or hand rubs, and
automated monitoring of the use of sinks and hand rub dispens-
ers. However, methods based on product consumption cannot
determine if hand hygiene actions are performed at the right
moment during care or if the technique is correct. The advan-
tages, however, are that they are simple and can be continu-
ous. The amount of alcohol-based hand rub used by healthcare
workers has been selected as one of the indicators by the WHO
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Guidelines on Hand Hygiene in Health Care.64
Statement 6
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Appropriate intravenous SAP (one-shot) should be administered
within 120 minutes considering the half-life of the antibiotic.
Additional intraoperative doses should be administered for pro-
cedures exceeding two half-lives of the antibiotic or with asso-
ciated significant blood loss (more than 1.5 L). The duration of
SAP should not exceed 24 hours. Any antibiotic administration
24 hours after the intervention has to be defined as therapy.
(Moderate quality of evidence, strong recommendation).
At the moment, the expert panel has no recommendations on
the use of oral antibiotic prophylaxis (No recommendations).
Although SAP plays a pivotal role in reducing the rate of SSIs,
other factors such as attention to basic infection prevention and
control strategies may have a strong impact on the occurrence
of SSIs.65
Although clinical practice guidelines for SAP have been pub-
lished, high rates of SAP prescribing practices not compliant
with guidelines are common and may contribute to suboptimal
patients’ outcomes, cause adverse effects, and be an important
driver of AMR.35
SAP should be recommended for surgical procedures having
a high risk of postoperative SSIs or when foreign material is
implanted. Antibiotic agents prescribed for surgical prophylaxis
should be nontoxic and inexpensive and should have in vitro
activity against the common organisms that can cause the post-
operative SSIs after a specific surgical procedure.66 Adequate
concentrations of antibiotics should be present in the surgical
site for the duration of the procedure. Intravenous SAP should
be administered within 120 minutes considering the half-life of
the antibiotic.
To value the correct timing of SAP and compare the differ-
ent timing intervals, a systematic review and meta-analysis were
published in 2017.67 The meta-analysis demonstrated that the
administration of SAP more than 120 minutes before the inci-
sion or after the incision was associated with a higher risk of
SSIs than the administration less than 120 minutes before the
incision.
Weber et al68 in 2017 published a randomized controlled trial
to evaluate the optimal timing of SAP consisting of single-shot,
intravenous infusion of 1.5 g of cefuroxime, a cephalosporin of
second-generation with a short half-life, associated with 500 mg
metronidazole in colorectal surgery. A total of 5,580 patients
were randomly assigned to the early group, 30–75 minutes
before the incision (2,798 patients), or the late group, 0–30
minutes before the incision (2,782 patients). Five-thousand
one-hundred seventy-five patients were analyzed. The authors
did not find any significant differences between the two groups.
An observational cohort study conducted in a Dutch tertiary
medical center69 was published in 2021 to evaluate if the risk of
SSIs differed after administration of SAP within 60–30 or 30–0
minutes before the surgical site incision. There was no conclu-
sive evidence of a difference in risk of SISs after SAP administra-
tion 60–30 minutes or 30–0 minutes before incision.
From a pharmacokinetic point of view, additional intraop-
erative doses should be administered for procedures exceeding
two half-lives of the antibiotic or with associated significant
blood loss (more than 1.5 L). It was confirmed by a recent
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meta-analysis.70 The meta-analysis included two randomized
controlled trials and eight cohort studies, involving 9,470
patients. Although there was heterogeneity among administered
antibiotics, intraoperative redosing of SAP reduced the inci-
dence of SSIs compared with a single dose preoperative SAP in
any type of surgery.
There is no evidence to support the use of SAP for more than
24 hours after the surgical procedure.35,71
Increasing duration of SAP was associated with a higher risk
of AKI and C. difficile infection, leading to no additional reduc-
tion of SSIs in a multicenter, national retrospective cohort study
published in 2019.40
Optimal timing for SAP as well as avoiding the prolonga-
tion of SAP are strong recommendations in the WHO guidelines
for the prevention of SSIs supported by a moderate quality of
evidence.12
The role of oral antibiotic prophylaxis and mechanical
bowel preparation (MBP) in colorectal surgery remains con-
troversial. Although the use of oral antibiotics in combination
with MBP is a strategy employed widely in North America,72
it remains much less common across Europe. The reasons for
avoidance of MBP in Europe are difficult to investigate, but the
increase in ERAS protocols excluding routine MBP may be a
reason.73 Evidence suggests that MBP use in addition to oral
antibiotics as part of a bowel-cleansing protocol is beneficial
with respect to SSI.12 The impact of the use of oral antibiotics
in the absence of MBP with regard to SSIs has not been estab-
lished.69 Moreover, the value of employing different regimens of
oral antibiotics has also not been clearly established. Most tri-
als have used the combination of an aminoglycoside (neomycin
or kanamycin) with a macrolide such as erythromycin or with
metronidazole.74
At the moment, the expert panel has no recommendations on
the use of oral antibiotic prophylaxis.
The increasing frequency of patients’ colonization with
extended-spectrum beta-lactamases (ESBLs) producers and
other MDRB may threaten the efficacy of routine SAP and
perioperative patient pathways.75
Optimizing clinical practice is crucial to mitigate AMR and
limit SSIs associated with MDRB. Future research is urgently
required to establish effective and appropriate SAP in those
patients colonized with MDRB.
Statement 7
Hair should not be removed from the surgical site unless it inter-
feres with the operation. If hair removal is necessary, it should
be made by a clipper. Razors for hair removal should not be
used because they increase the risk of SSIs (Moderate quality of
evidence, strong recommendation).
Adherence to aseptic techniques is integral to the prevention
of SSIs. One of the measures to prevent SSIs is the preopera-
tive preparation of the operative site, including not to remove
hair from the surgery site unless it interferes with the surgical
procedures. A Cochrane systematic review on preoperative hair
removal to reduce SSIs was published in 2021.76 The review
included 19 randomized and six quasi-randomized trials (8,919
participants). The authors concluded that there were probably
fewer SSIs when hair was not removed compared with shaving
with a razor (moderate-certainty evidence).
Another meta-analysis of published randomized controlled
trials about hair removal for the prevention of SSIs was pub-
lished in 2017.77 This meta-analysis included 14 trials, 11 ran-
domized controlled trials and three controlled clinical trials. The
authors concluded that hair removal should be avoided unless
necessary. When hair removal is necessary, the meta-analysis
suggests that clipping is more effective in preventing SSIs than
shaving or depilatory cream.
 Sartelli et al. • Volume 42 • Number 2 • 2022
The 2016 WHO guidelines12 for the prevention of surgi-
cal site infections strongly recommend not to remove the hair
from the surgical site unless it interferes with the operation,
and if removal is necessary, it should be made by a clipper. The
meta-analysis conducted by WHO experts included 15 random-
ized or quasi-randomized trials comparing the effect of preoper-
ative hair removal versus no hair removal or different methods
of hair removal (shaving, clipping, and depilatory cream).12 A
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moderate quality of evidence demonstrated that clipping or no
hair removal has a significant benefit in reducing the risk of SSI
when compared with shaving.
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Statement 8
Alcohol-based solutions of chlorhexidine for surgical site skin
preparation should be used in patients undergoing surgical pro-
cedures. Alcohol-based solutions of povidone-iodine may be
used as an alternative to alcohol-based solutions of chlorhexi-
dine. If the surgical site is next to a mucous membrane, aqueous
solutions should be used (Moderate quality of evidence, strong
recommendation).
Another important point of SSI prevention during skin prepa-
ration is the meticulous preoperative disinfection of the skin. It
aims to reduce the microbial load on the patient’s skin as much
as possible before incising the skin. Skin commensals include
many bacteria with little pathogenicity but also potentially
pathogenic bacteria such as S. aureus. The number of bacteria
on the skin can be greatly reduced, limiting the risk of SSIs, by
appropriate skin disinfection.
Current evidence demonstrates that alcohol-based prepara-
tions are more effective than aqueous-based preparations, and
should be used, if they are not contraindicated. However, which
is the most adequate alcohol-based solution is still a contro-
versial issue.78,79 Many control trials80–84 compared the efficacy
of aqueous-based povidone-iodine solutions with alcohol-based
chlorhexidine solutions for preventing SSIs and reported alco-
hol-based chlorhexidine as more effective.
A well-conducted randomized single-center study published
in 201685 demonstrated that the use of alcohol-based solution
of chlorhexidine for preoperative skin antisepsis resulted in a
significantly lower risk of SSIs after cesarean delivery compared
with the use of alcohol-based solution of povidone-iodine. On
the other hand, another single-center randomized study86 com-
pared alcohol-based solution of chlorhexidine, alcohol-based
solution of povidone-iodine, and both applied sequentially,
demonstrating that the skin preparation techniques resulted in
similar rates of SSIs after cesarean delivery.
The 2016 WHO guidelines for the prevention of surgical
site infections recommend, with moderate quality of evidence,
alcohol-based solutions of chlorhexidine for surgical site skin
preparation in patients undergoing surgical procedures.12 The
meta-analysis conducted by the WHO experts included 17
randomized control trials.87 Six randomized controlled trials
compared alcohol-based solutions of chlorhexidine with alco-
hol-based solutions of povidone-iodine and found significantly
lower risk of SSIs with alcohol-based solutions of chlorhexi-
dine. However, four of the six randomized control trials did not
report SSIs in at least one study arm, and in most studies, the
main endpoint was the number of colony-forming units rather
than SSIs.
The NICE guidelines suggest alcohol-based solutions of chlor-
hexidine as the first choice unless contraindicated or the surgical
site is next to a mucous membrane.15 The 2017 CDC guidelines for
the prevention of SSIs recommend the use of alcohol-based anti-
septic solutions without differentiating alcohol-based solutions
of chlorhexidine or alcohol-based solutions of povidone-iodine.13
The Asia Pacific Society of Infection Control (APSIC)24 suggests
alcohol-based skin antiseptic preparations without differentiating
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alcohol-based solutions of chlorhexidine or alcohol-based solu-
tions of povidone-iodine.
Alcohol-based antiseptics are flammable. Alcohol-based anti-
septics should be allowed time to dry completely (about 3 min-
utes, longer in areas with excess hair) to limit fire hazard.
Statement 9
Perioperative patient’s clinical condition, including maintain-
ing normal body temperature (normothermia), should be opti-
mized and monitored (Moderate quality of evidence, strong
recommendation).
The WHO global guidelines suggest the use of warming
devices in the operating room and during the surgical pro-
cedure for patient body warming with the purpose of reduc-
ing SSIs.12 Even mild degrees of hypothermia can increase SSI
rates. Hypothermia may directly impair neutrophil function or
impair it indirectly by triggering subcutaneous vasoconstriction
and subsequent tissue hypoxia. In addition, hypothermia may
increase blood loss, leading to wound hematomas or a need for
transfusion, both of which can increase rates of SSIs.88,89 Several
randomized controlled trials have shown the benefits of periop-
erative warming to reduce SSI rates.90–92
The most frequently used technique to prevent perioperative
hypothermia is active body surface warming systems, which
generate heat mechanically (heating of air, water, or gels) that
is transferred to the patient via skin contact. A Cochrane sys-
tematic review to evaluate the effectiveness of perioperative
active body surface warming systems was published in 2016.
The review demonstrated a beneficial effect of warming systems
in terms of a lower rate of SSIs and complications, at least in
patients undergoing abdominal surgery. A beneficial effect was
also demonstrated on major cardiovascular complications in
patients with substantial cardiovascular disease, although the
evidence was limited.93
The WHO global guidelines for the prevention of SSIs stated
that the evidence was insufficient to identify a target tempera-
ture to be reached and maintained.12
In 2014 a collaborative document led by the Society for
Healthcare Epidemiology of America (SHEA), the Infectious
Diseases Society of America (IDSA), the American Hospital
Association (AHA), the Association for Professionals in
Infection Control and Epidemiology (APIC), and The Joint
Commission,89 recommended a minimum temperature of 35.5
°C during the perioperative period.
Considering that “hypothermia” is defined as a core tempera-
ture <36 °C, the accepted target may be core temperature >36 °C.
Statement 10
Where available, triclosan-coated sutures should be used to pre-
vent SSIs (Moderate quality of evidence, strong recommendation).
SSIs may arise when bacteria colonize the surgical sutures,
creating a biofilm. The biofilm establishes immunity from both
antibiotic treatment and the host immune system.94 Once this
biofilm develops, there is an increased chance of SSIs develop-
ing. In vitro and in vivo studies have shown the effectiveness of
triclosan-coated sutures95 in inhibiting colonization of sutures.
Triclosan-coated sutures were shown to be nontoxic, noncar-
cinogenic, and nonteratogenic.96
A large number of randomized controlled trials and
meta-analyses have been performed with contrasting results on
the effectiveness of triclosan-coated sutures.
In 2014, the largest conducted randomized controlled trial
on this topic was published by Diener et al.97 It was performed
in 24 German hospitals and demonstrated that triclosan-coated
polydioxanone (PDS Plus) did not reduce the occurrence of SSIs
after elective midline laparotomy.
 Sartelli et al. • Volume 42 • Number 2 • 2022
Another study, published in 2015,98 did not demonstrate
the benefits of triclosan-coated sutures. However, the authors,
despite good randomization methods, did not exclude baseline
imbalances that could have interfered with the primary outcome
of the study.
Many meta-analyses have demonstrated that triclosan-coated
sutures are effective,99–110 but in some meta-analyses, the effect
size differs substantially among subgroups.109 It has been proven
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that triclosan-coated sutures are more effective in studies using
polyglactin 910 sutures than in those using polydioxanone.109
These findings can explain the results of the study by Diener et
al,97 as they investigated polydioxanone. A possible reason for
the variation in effect between suture types may be found in
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the features of sutures. Polydioxanone is a monofilament suture
and bacterial adherence to polydioxanone may be lower than
that to a braided suture such as polyglactin 910.111 Therefore, a
polyglactin 910 suture may have more potential to be colonized
than a monofilament suture, and thereby may benefit more
from an active antibacterial suture. Moreover, polydioxanone
is generally used to close the fascia, whereas polyglactin 910 is
used to close the subcutaneous tissue. The majority of SSIs are
described as superficial and in the study by Diener et al.,97 the
most detected SSIs were superficial. It indicates that the majority
of described SSIs in this study occurred in a different anatomical
layer from that for which the intervention was performed.109
Antimicrobial sutures should be used for the closure of all
incisional wound layers throughout the whole incision, mitigat-
ing the risk of wound contamination and the occurrence of SSIs.
Polydioxanone sutures should be used for closing the fascial
layer. Triclosan-coated polyglactin sutures should be used for
closing the subcutaneous layer.
The role of triclosan-coated sutures in reducing the incidence
of SSIs compared with uncoated sutures has been demonstrated
by 12 meta-analyses.99–110
Two recent and large systematic reviews found triclosan-coated
sutures significantly reduced the incidence of SSIs.109,110 The first
meta-analysis, published in 2017 by de Jonge et al,109 included 21
randomized control trials and involved 6,462 patients. SSIs were
reduced significantly by the use of triclosan-coated sutures com-
pared with a comparable uncoated variant (a relative risk reduc-
tion of 15% for the use of triclosan-coated sutures).
The second meta-analysis, published in 2019 by Ahmed
et al,110 included 25 randomized control trials and involved
11,957 patients. The meta-analysis demonstrated that tri-
closan-coated sutures significantly reduced the risk of SSIs at
30 days after the surgical procedure, both in clean and con-
taminated surgery.
Finally, a systematic review and meta-analysis investigating
the efficacy of triclosan-coated sutures for preventing SSIs in the
specific field of digestive surgery was published in 2018.106 In the
10 randomized control trials, the incidence rates of SSIs were
8.9% using coated sutures and 12.1% using noncoated sutures.
The use of triclosan-coated sutures is now suggested to
reduce the risk of SSIs by WHO,12 CDC,13 the American College
of Surgeons and Surgical Infection Society,14 NICE,15 and the
World Society of Emergency Surgery.112
Statement 11
On an individual level, every surgeon should have the necessary
knowledge, skills, and abilities to implement effective IPC prac-
tices. However, surgeons with special interest and knowledge
in surgical infections should be incorporated into the infection
control team and recognized as “champions” (Very low quality
of evidence, strong recommendation).
Surgeons are at the forefront in preventing infections across
the surgical pathway. They are responsible for many of the pro-
cesses of healthcare that impact the risk of SSIs and play an
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important role in their prevention. In hospitals, cultural, con-
textual, and behavioral determinants influence clinical prac-
tice.113 Improving behavior in IPC remains a challenge. A range
of factors such as diagnostic uncertainty, fear of clinical fail-
ure, time pressure, or organizational contexts can complicate
the surgeons’ approach toward infections. However, changing
behavior is challenging.
Surgeons should have the necessary knowledge, skills, and abil-
ities to implement effective infection prevention and management
practices. Nonetheless, increasing knowledge alone may not be
sufficient and may not be effective in changing practice.114
Identifying a local opinion leader to serve as a champion may
be important because the “champion” may integrate best clinical
practices and drive colleagues in changing behaviors, working
on a day-to-day basis, and promoting a culture in which IPC is
of high importance.23 Surgeons with satisfactory knowledge of
surgical infections may provide feedback to the prescribers, inte-
grate the best practices among surgeons and implement change
within their own sphere of influence by interacting directly with
the infection control committee. Such a champion model has
been previously applied to surgical safety implementations in
general, such as surgical checklists, and plays a key role in suc-
cessful quality improvement at the hospital level.115
Conclusions
The following recommendations proposed in this document aim
to disseminate best practices among Italian surgeons and sum-
marize the ACOI recommendations on the prevention of SSIs.
Statement 1
As many HAIs may be preventable, each surgical department
should have in place and implement measures aimed at reducing
the risk of HAIs including SSIs, before, during, and after surgery.
Multidisciplinary educational projects should be implemented
aiming to increase knowledge and raise awareness and account-
ability (Moderate quality of evidence, strong recommendation).
Statement 2
Facility-based surveillance of HAIs, including SSIs, surveillance
should be performed to guide interventions with timely feed-
back of results to surgeons. Every surgical unit should know the
effectiveness of the adopted prevention strategies (Low quality
of evidence, strong recommendation).
Statement 3
An approved local protocol of surgical antibiotic prophylaxis
(SAP) according to the local microbiological epidemiology
should be in place in each surgical unit. Its appropriate appli-
cation should be periodically verified (Low quality of evidence,
strong recommendation).
Statement 4
Due to their demonstrated efficacy, optimizing patients’ physio-
logic function by enhanced recovery after surgery (ERAS) pro-
tocols and limiting perioperative blood transfusions by patient
blood management (PBM) protocols should be implemented to
improve the patient’s response to infections (Low quality of evi-
dence, strong recommendation).
Statement 5
Hand hygiene is the cornerstone of IPC. When optimally
performed, hand hygiene reduces HAIs and the spread of
 Sartelli et al. • Volume 42 • Number 2 • 2022
antimicrobial resistance. Correct hand hygiene should always
be performed during the surgical pathway. Its appropriateness
and the consumption of alcohol-based hand rub used by sur-
geons should be monitored periodically (Moderate quality of
evidence, strong recommendation).
Statement 6
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Appropriate intravenous SAP (one-shot) should be admin-
istered within 120 minutes considering the half-life of the
antibiotic. Additional intraoperative doses should be adminis-
tered for procedures exceeding two half-lives of the antibiotic
or with associated significant blood loss (more than 1.5 L).
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The duration of SAP should not exceed 24 hours. Any anti-
biotic administration 24 hours after the intervention has to
be defined as therapy. (Moderate quality of evidence, strong
recommendation).
At the moment, the expert panel has no recommendations on
the use of oral antibiotic prophylaxis (No recommendations).
Statement 7
Hair should not be removed from the surgical site unless it inter-
feres with the operation. If hair removal is necessary, it should
be made by a clipper. Razors for hair removal should not be
used because they increase the risk of SSIs (Moderate quality of
evidence, strong recommendation).
Statement 8
Alcohol-based solutions of chlorhexidine for surgical site skin
preparation should be used in patients undergoing surgical pro-
cedures. Alcohol-based solutions of povidone-iodine may be
used as an alternative to alcohol-based solutions of chlorhexi-
dine. If the surgical site is next to a mucous membrane, aqueous
solutions should be used (Moderate quality of evidence, strong
recommendation).
Statement 9
Perioperative patient’s clinical condition, including maintain-
ing normal body temperature (normothermia), should be opti-
mized and monitored (Moderate quality of evidence, strong
recommendation).
Statement 10
Where available, triclosan-coated sutures should be used to pre-
vent SSIs (Moderate quality of evidence, strong recommendation).
Statement 11
On an individual level, every surgeon should have the necessary
knowledge, skills, and abilities to implement effective IPC prac-
tices. However, surgeons with special interest and knowledge
in surgical infections should be incorporated into the infection
control team and recognized as “champions” (Very low quality
of evidence, strong recommendation).
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ling analysis. Lancet Infect Dis. 2019;19:56–66.
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