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| EVIDENCE-BASED MEDICINE |
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| Year : 2017 | Volume
: 15
| Issue : 1 | Page : 59-60 |
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WHO guidelines to prevent surgical site infections (for low- and middle-income countries)
Tony Abraham Thomas
Christian Medical College, Vellore, India
| Date of Web Publication | 17-Feb-2017 |
Correspondence Address:
Tony Abraham Thomas
Christian Medical College, Vellore
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/cmi.cmi_8_17
How to cite this article:
Thomas TA. WHO guidelines to prevent surgical site infections (for low- and middle-income countries). Curr Med Issues 2017;15:59-60 |
Sources: This is a summary of the following articles.
1. Allegranzi B, Bischoff P, de Jonge S, Kubilay NZ, Zayed B, Gomes SM, et al. New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: An evidence-based global perspective. Lancet Infect Dis 2016;16:e276-87.
2. Allegranzi B, Zayed B, Bischoff P, Kubilay NZ, de Jonge S, de Vries F, et al. New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis 2016;16:e288-303.
| Introduction | |  |
Infections associated with a surgical procedure are mostly preventable, and their incidence depends on the practices followed in preoperative preparation, during the procedure, and after surgery. Despite best practices based on recommendations in the past, surgical site infections (SSIs) impose a significant burden on patients who undergo surgery, especially in low-income countries. A 2010 WHO report stated that up to a third of patients who had surgery in low- and middle-income countries were burdened with surgery-related infections with a prevalence of up to twenty times that of high-income countries. One of the problems with recommendations developed in the past was that they were not universally applicable in all geographic distributions. The WHO developed global guidelines to address this issue, and their recommendations were published as two articles in the journal Lancet (see source details above).
| the Who Guidelines | | |
The WHO guidelines were developed by an international team with a wide geographical distribution, consisting of surgeons, anesthetists, nurses, infectious disease specialists, infection prevention and control professionals, and patient representatives. The intended audience was the entire surgical team involved in a procedure. According to the WHO, these are the most extensive set of global guidelines ever produced on this subject and are applicable in any country.
The guidelines were evidence-based recommendations and were rated on the strength of the evidence as either “Strong” or “Conditional.” Strong recommendations are applicable in most (if not all) situations while the conditional recommendations would require a decision involving the medical professionals and the patients. These recommendations are summarized in [Table 1]. | Table 1: Strong recommendations (WHO guidelines to prevent surgical site infections)
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| Conditional Recommendations | | |
Although backed with evidence comparable with the “strong” recommendations, the following have been considered “conditional” because of issues such as local availability and cost-effectiveness in regions with limited resources. Some of the important conditional recommendations are enlisted below as follows:
- Preoperative bathing - Patients should bathe or shower before surgery; either a plain soap or an antimicrobial soap may be used for this purpose
- Antibiotic sealants - The use of these sealants after surgical site preparation does not provide additional protection from infection. These are sterile films or film-forming cyanoacrylate-based sealants which are supposed to prevent migration of flora from surrounding skin. They significantly increase the cost of surgery
- Warming devices - The use of warming devices to maintain normal body temperature of patients is recommended
- Adhesive incise drapes and wound-protector devices - Adhesive incise drapes and wound-protector devices have not shown to decrease the incidence of SSI. They also significantly increase costs and are therefore not recommended
- Advanced dressings - Dressings containing hydrocolloid, hydrogels, fibrous hydrocolloid, or polyurethane matrix hydrocolloid dressings, and vapor-permeable films were not found to be superior to standard dressings. They also increase costs
- Laminar air flow - In the operating room, laminar air flow was not found to be superior to adequate natural ventilation, even for procedures such as total arthroplasty.
| Discussion | | |
The guidelines are comprehensive and aimed at low- and middle-income countries. The wide geographical representation of those involved in the process of outlining these guidelines provides a strong credibility factor for the universal application of these guidelines in any country. Affordability of treatment is a major factor in low-income countries, and interventions that offer questionable or only minimal benefit have been rightly considered “conditional” recommendations or not recommended. Of particular interest, in this aspect is the use of adhesive drapes, wound-protector devices, and “advanced” dressings as these raise costs disproportionate to the benefit obtained. However, it must be remembered that each country and location have unique challenges, and there may be interventions suggested in these guidelines which may not be practically applicable in all situations.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
[Table 1]
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