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 Table of Contents  
Year : 2018  |  Volume : 6  |  Issue : 1  |  Page : 1-12

A review of prevention of surgical site infections in Indian hospitals based on global guidelines for the prevention of surgical site infection, 2016

1 MD Head-Quality and Patient Safety at Fortis Healthcare Limited, Delhi, India
2 Senior Consultant, Obstetrics and Gynaecology, Minimal Invasive Gynaecology Royal Free Hospital, London, Robotic Training IRCAD, Strasbourg, France, Day Care Endoscopy Birmingham City Hospital, Birmingham, UK, Diploma Operative Pelviscopy Kiel, Germany
3 Chairman, Max Institute of Cancer care, New Delhi, India
4 MBBS, MS, MNAMS, FRCS (LONDON) FIMSA, FAIS, FICS, FACS, FIAGES, FALS, Chairman Max Institute of Minimal Access, Metabolic and Bariatric Surgery, Executive Vice Chairman at Max Healthcare, New Delhi, India
5 MBBS, MHA, FNAMS, FIHE, FAHA, Medical Superintendent, All India Institute of Medical Sciences, New Delhi, India
6 DSc MD ChM FRCS FACS FLS, Emeritus Professor of Surgery, University of Newcastle upon Tyne, Emeritus Professor of Clinical Sciences, ISIaIP, University of Huddersfield, Visiting Professor, Imperial College, London, UK
7 Chairman (Heart Surgery), Max Smart Super Speciality Hospital, New Delhi, India
8 Chairman of Bone and Joints Institute at Medanta Hospital, Karnataka, India
9 Head of Department of Day Care Surgery at Ramakrishna Group of Hospitals in Bangalore, Karnataka, India
10 DGO, MD (OBGY), Diploma in Endoscopy, UK, USA
11 Head, Department of Surgical Disciplines, AIIMS, New Delhi, India
12 Consultant Cardiovascular Thoracic Surgeon, Mumbai, Maharashtra, India

Date of Web Publication6-Aug-2018

Correspondence Address:
Dr. G K Mani
Max Smart Super Speciality Hospital, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpsic.jpsic_29_17

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While the global estimates of surgical site infection (SSI) have varied from 0.5% to 15%, studies in India have consistently shown higher rates ranging from 23% to 38%. The incidence of SSI may be influenced by factors such as pre-operative care, the theatre environment, post-operative care and the type of surgery. Many other factors influence surgical wound healing and determine the potential for, and the incidence of, infection. Therefore, the prevention of these infections is complex and requires the integration of a range of preventive measures before, during and after surgery. No standardised guidelines backed by evidence are currently established in India for the prevention of SSI. Hence, there is a need for an adaptable, executable National Guideline for low- and middle-income countries which includes India. An effort to draw out most doable and must doable action points to prevent SSI was undertaken by the panelists involved in this paper on the basis of recent global guidelines for the prevention of SSI.

Keywords: Drain removal, glucose control, hair removal, hand preparation, mechanical bowel preparation, pre-operative bathing, surgical antibiotic prophylaxis, surgical site infection prevention, surgical site preparation, triclosan-coated sutures, wound irrigation

How to cite this article:
Arora A, Bharadwaj P, Chaturvedi H, Chowbey P, Gupta S, Leaper D, Mani G K, S Marya S K, Premnath R, Quadros K, Srivastava A, Tendolkar A. A review of prevention of surgical site infections in Indian hospitals based on global guidelines for the prevention of surgical site infection, 2016. J Patient Saf Infect Control 2018;6:1-12

How to cite this URL:
Arora A, Bharadwaj P, Chaturvedi H, Chowbey P, Gupta S, Leaper D, Mani G K, S Marya S K, Premnath R, Quadros K, Srivastava A, Tendolkar A. A review of prevention of surgical site infections in Indian hospitals based on global guidelines for the prevention of surgical site infection, 2016. J Patient Saf Infect Control [serial online] 2018 [cited 2023 Mar 30];6:1-12. Available from: https://www.jpsiconline.com/text.asp?2018/6/1/1/238599

  Introduction Top

Healthcare-associated infections (HAIs) are acquired by patients when receiving care, in both primary and secondary environments and are the most frequent adverse event affecting patient safety worldwide. Although the global burden remains unknown because of the difficulty to gather reliable data, it is estimated that hundreds of millions of patients are affected by HAIs each year, leading to significant mortality and huge financial strain on health systems. At present, no country is free from the burden of disease caused by HAIs and antimicrobial, specifically antibiotic, resistance (AMR). Of every 100 hospitalised patients at any given time, seven in developed and 15 in developing countries will acquire at least one HAI. The endemic burden of HAI is also significantly (at least 2—3 times) higher in low- and middle-income countries (LMICs) than in high-income nations. Recent work by the World Health Organization's (WHO) Clean Care is Safer Care program shows that surgical site infection (SSI) is the most surveyed and frequent type of HAI in LMICs and affects up to one-third of the patients who have undergone a surgical procedure.[1]

In LMICs, the pooled incidence of SSI is 11.8/100 surgical procedures (range 1.2—23.6). SSI is one of the most common post-operative complications and causes significant post-operative morbidity and mortality. While the global estimates of SSI have varied from 0.5% to 15%, studies in India have consistently shown higher rates ranging from 23% to 38%.[2] SSI also poses a significant health economic burden on individual patients. Various studies have reported a high SSI incidence rate in India. A study by Subramanian et al. at the All India Institute of Medical Sciences estimated an infection rate of 24.8%. A similar study by Ganguly et al. in Aligarh reported an infection rate of 38.8%. The incidence of SSI was found to be related to the type of wounds and varied with the operation location. The incidence of SSI was highest after cardiovascular[3],[4] and gastrointestinal surgery,[5],[6] and the most common pathogens found in SSIs were Staphylococcus aureus, Pseudomonas aeruginosa and Escherichia coli.[3],[4],[5],[7],[8],[9],[10],[11],[12],[13] The infection rate increased with the order of operation on the operation list.

Extent of the problem

SSIs are common complications which follow all types of operative procedures. Patients who develop an SSI are more likely to have an extended hospital stay with additional economic costs, mainly attributable to the extended length of stay. Indirect costs, such as loss of productivity by the patient and an increased burden on their careers, further add to the economic cost of SSI to healthcare systems. These infections are caused by exogenous (from the environment of the operating theatre or the surgical ward) and endogenous microorganisms (from the patients' own skin or opened viscus) which enter the operative wound during surgery. The incidence of SSI may be influenced by factors such as pre-operative care, the theatre environment, post-operative care and the type of surgery. Many other factors influence surgical wound healing and determine the potential for, and the incidence of, infection. Therefore, the prevention of these infections is complex and requires the integration of a range of preventive measures before, during and after surgery. However, the implementation of these measures is not standardised worldwide. No international/national guidelines are currently established in India for the prevention of SSI and inconsistency in the interpretation of evidence and recommendations among available national guidelines is frequently identified. Hence, there is a need for an adaptable, executable National Guideline for LMICs which includes India.[1]


The primary target audience for these recommendations is the surgical team: surgeons, nurses, technical support staff, anaesthetists and any professionals directly providing surgical care. Pharmacists and sterilisation unit staff will also be involved in some aspects of these guidelines. The recommendations are also intended to be used by policy-makers, senior managers and infection prevention and control professionals as the basis for developing national and local SSI protocols and policies and supporting staff education and training.[1] A diverse group of practitioners was therefore chosen for the Ethicon Advisory Board Panel to represent a wide and holistic view on SSI prevention and include a wide representation of healthcare management professionals with the aim of producing a guideline for better patient services. The primary object of this draft guideline is to make it suitable for all types of hospital. Therefore, the panelists were asked to deliberate on selected recommendations from the recently published WHO guideline for prevention of SSI, keeping in mind the current diverse healthcare environments in India.[14]

  Pre-Operative Interventions Top

Pre-operative bathing

WHO: It is good clinical practice for patients to bathe or shower prior to surgery. The panel suggests that either a plain or antimicrobial soap may be used for this purpose (Conditional recommendation, moderate quality of evidence). The panel decided not to formulate a recommendation on the use of chlorhexidine gluconate (CHG)-impregnated cloths for the purpose of reducing SSI due to the limited and very low-quality evidence.[1]

In India, it is important to start with awareness of basic hygiene, cognizant of variant weather conditions and its impact on hygiene, such as excessive sweating. The panelists agreed that there is no standardisation needed for the type of soap used (liquid or bar, beauty soap or medicated soap) and recommending 'medicated soap' may be a better option. However, on further deliberation with respect to supportive evidence, it was clear that there is little evidence to support 'medicated soap' for SSI reduction. It was suggested that a recommendation equivalent to that suggested by the Centers for Disease Control of the US (CDC) should be used; i.e., 2 baths/showers-one the night before and one on the morning of surgery. It was added that cardiac surgeons should take the precaution to advise their patients to clean axilla, and other areas close to surgical field, with CHG if possible. The panel decided to adopt and follow WHO recommendation for pre-operative bathing.[14]

Summary of the evidence

Nine studies (seven randomised controlled trials [RCTs] and two observational studies), including a total of 17, 087 adult patients,[15],[16],[17],[18],[19],[20],[21],[22],[23] investigated pre-operative bathing or showering with an antimicrobial soap compared to plain soap. There is a moderate quality of evidence that bathing with CHG soap does not significantly reduce SSI rates compared to bathing with plain soap (Odds Ratio [OR]: 0.92; 95% confidence interval [CI]: 0.80—1.04). There is very low quality evidence that pre-operative bathing with CHG-impregnated cloths may reduce SSI rates when compared to either bathing with CHG soap or no bathing. The body of retrieved evidence focused on adult patients and no studies were available in the pediatric population. Several organisations, such as National Institute for Health and Care Excellence (NICE) 2008 and 2013; UK High Impact intervention bundle 2011, have issued recommendations regarding pre-operative bathing. Most recommended bathing with soap on the day of the operation or the day before. Only the US Institute of Healthcare Improvement bundle for hip and knee arthroplasty recommends CHG soap for pre-operative bathing.

Optimal timing for pre-operative surgical antibiotic prophylaxis

WHO: The panel recommends the administration of surgical antibiotic prophylaxis (SAP) prior to the surgical incision when indicated (depending on the type of operation) (Strong recommendation, low quality of evidence). The panel recommends the administration of SAP within 120 min before incision, while considering the half-life of the antibiotic (Strong recommendation, moderate quality of evidence).

The irrational use of antibiotics is a major problem of present-day medical practices and its consequences include ineffective treatment, development of resistance to antibiotics, adverse effects and an economic burden on patients and society. Widespread and indiscriminate use of broad-spectrum antibiotics has contributed to the emergence of multidrug resistance. Existing evidence suggests that there is a causal association between antibiotic usage in hospitals and AMR. Appropriate antibiotic prophylaxis has also been shown to be effective in reducing the incidence of SSI. In India, no consistency was noted in the timing of administration of prophylactic antibiotics, and no guidelines are being adhered to regarding prophylactic antibiotic administration. The panel also deliberated on the optimal timing of administration because the timing of administration at f induction of anaesthesia could represent a long-time gap between injection and incision. Other factors pertaining to IV antibiotic administration timing included pharmacokinetics and half-life, type of surgery and duration. For example, the American Society of Health-Care Pharmacists (ASHP) guidelines recommend 15 min before incision. Vancomycin needs a long infusion time 30—60 min which needs matching to incision time. It was decided to agree with the above recommendation from the WHO.[1],[14]

The panel recommends the administration of the first dose of antimicrobial within 60 min before the surgical incision. The administration of fluoroquinolones and vancomycin should begin within 120 min before surgical incision because of the prolonged infusion times required for these drugs.[14]

Summary of the evidence

A total of 13 observational studies,[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36] including a total of 53,975 adult patients, were identified; and 2 were from multiple centres. No RCTs were identified. The evidence focused on adult patients. Moderate quality evidence shows that SAP administration before 120 min pre-incision is associated with a significantly higher risk of SSI when compared to administration within 120 min (OR: 5.26; 95% CI: 3.29—8.39). Furthermore, there is low-quality evidence that the administration of SAP after incision is associated with a significantly higher risk of SSI compared to administration before incision (OR: 1.89; 95% CI: 1.05—3.4). In addition, low-quality evidence shows that the administration within 60 min before incision has neither benefit nor harm for the reduction of SSI rates compared to administration between 60 and 120 min before incision. Similarly, SAP administration within 30-0 min before incision has neither benefit nor harm for the reduction of SSI rates when compared to administration within 60-30 min prior to incision. The administration of SAP before surgery has been specified in many clinical practice guidelines issued by professional societies or national authorities, such as those published by the ASHP-2013, Society for Healthcare Epidemiology of America (SHEA 2014), Infectious Diseases Society of America (IDSA 2014), recommend administration within 60 min before incision (120 min for vancomycin and fluoroquinolones due to prolonged infusion times). However, these recommendations are not based on systematic reviews of the literature and meta-analysis or a rigorous evaluation of the quality of the available evidence.

Mechanical bowel preparation and the use of oral antibiotics

WHO: The panel suggests that pre-operative oral antibiotics combined with mechanical bowel preparation (MBP) should be used to reduce the risk of SSI in adult patients undergoing elective colorectal surgery (Conditional recommendation, moderate-quality evidence). The panel recommends that MBP alone (without administration of oral antibiotics) should not be used for the purpose of reducing SSI in adult patients undergoing elective colorectal surgery (Strong recommendation, moderate quality evidence).

MBP is widely undertaken in the US but less so in the UK. The Cochrane collaboration suggests no bowel preparation is required before right-sided colectomy but may be required for the left haemicolectomy or distal resections, which matches current the practice in India. The panelists suggested that it is preferable to empty the large bowel to reduce the effect of anastomotic leak after surgery. Oral antibiotics were not recommended as more recent had shown no advantage study.[1],[14]

Summary of the evidence

Twenty-four RCTs[37],[38],[39],[40],[41],[42],[43],[44],[45],[46],[47],[48],[49],[50],[51],[52],[53],[54],[55],[56],[57],[58],[59],[60] were identified comparing either MBP with no MBP or the combined intervention of MBP and oral antibiotics with MBP and no oral antibiotics. Eleven RCTs[37],[38],[39],[40],[41],[42],[43],[44],[45],[46],[47] including a total of 2416 MBP combined patients and comparing pre-operative with the administration of oral antibiotics compared with MBP and no oral antibiotics were identified. Moderate quality evidence showed that pre-operative MBP combined with oral antibiotics reduces the SSI rate when compared to MBP only. A total of 13 RCTs[48],[49],[50],[51],[52],[53],[54],[55],[56],[57],[58],[59],[60] including a total of 4869 patients and comparing MBP with no MBP were identified. Moderate quality evidence shows that pre-operative MBP has neither benefit nor harm for the reduction of SSI rates when compared to no MBP at all. Of the 13 trials comparing MBP with no MBP, 3 reported specifically on SSI-attributable mortality,[51],[56],[60] but they did not find any statistical difference in the mortality rate. Some observational studies[61],[62],[63] using registry databases suggested that oral antibiotics may be effective in reducing the risk of SSI, irrespective of being combined with MBP. In addition, a prospective, randomised study[64] strongly supports the use of oral antibiotics as part of a bundled intervention; however, in combination with MBP. SHEA/IDSA 2014 recommend to use MBP for colorectal procedures, but only combined with oral antibiotics. However, these recommendations are not based on systematic reviews of the literature and meta-analysis or a rigorous evaluation of the quality of the available evidence.

Hair removal

The WHO panel recommends that in patients undergoing any surgical 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 pre-operatively or in the operating room (OR) (Strong recommendation, moderate quality of evidence).

The Indian group of panelists agreed unanimously without any deliberation for this recommendation.[14]

Summary of the evidence

A total of 15 RCTs or quasi-randomised trials[65],[66],[67],[68],[69],[70],[71],[72],[73],[74],[75],[76],[77],[78],[79] comparing the effect of pre-operative hair removal compared with no hair removal or different methods of hair removal (shaving, clipping and depilatory cream) were identified. In meta-analyses, no hair removal and clipping are similar regarding potential to cause microscopic skin trauma. A low to very low quality of evidence shows that shaving, clipping or the use of depilatory cream has neither benefit nor harm related to the reduction of the SSI rate when compared to no hair removal. However, when hair is removed, there is a low-quality of evidence showing that clipping has a significant benefit in reducing the SSI rate compared to shaving. When clipping and no hair removal were combined in the meta-analysis, a moderate quality of evidence showed that both are associated with a significantly lower risk of SSI when compared to shaving. A moderate quality of evidence shows that hair removal the day before surgery does not affect the SSI rate compared to hair removal on the day of surgery.

Surgical site preparation

WHO: The panel recommends alcohol-based antiseptic solutions based on CHG for surgical site skin preparation in patients undergoing surgical procedures (Strong recommendation, low-to-moderate quality of evidence).

The use of CHG aqueous followed by alcoholic CHG was recommended by the panelist. Initially, Povidone Iodine (PVP-I), then aqueous CHG and now alcoholic CHG is usually used in India according to the panelists. Alcohol-based solutions should be allowed to dry. The evidence is only moderate and subjective for alcoholic CHG use and should be used with caution in pediatric procedures and in vaginal mucosa. Panelists deliberated the use of CHG for vaginal prep. Vaginal epithelium has no mucus glands and keratin, therefore, is more prone to irritation with antiseptic use. Alcohol-based solutions carry the chance of electrosurgical burns if not allowed to dry completely which may be difficult because of vaginal pooling. OBGYN literature data suggest the concentration of CHG to be the main irritant. About 1%—2% solutions of CHG better tolerated in obstetric cases. Four per cent solution is well tolerated in non-pregnant cases for single applications. CHG is a better choice than PVP-I. Because of rapid onset and persistent antimicrobial activity.[14]

Summary of evidence

17 RCTs[80],[81],[82],[83],[84],[85],[86],[87],[88],[89],[90],[91],[92],[93],[94],[95],[96] comparing antiseptic agents (PVP-I and CHG) in aqueous or alcohol-based solutions were identified.

The following comparisons were evaluated in the selected studies:

  1. Alcohol-based antiseptic solutions compared with aqueous solutions

    • CHG in an alcohol-based solution compared with PVP-I in an aqueous solution b) PVP-I in an alcohol-based solution compared with PVP-I in an aqueous solution

  2. CHG compared with PVP-I-both in alcohol-based solutions Moderate-quality evidence shows that alcohol-based antiseptic solutions are overall more effective compared to aqueous solutions in reducing the risk of SSI. More specifically, a low quality of evidence shows a significant reduction of the SSI risk with the use of alcohol-based CHG compared to PVP-I in alcohol-based solutions. Moderate quality evidence shows also a significant benefit in using CHG alcohol-based solutions compared to aqueous PVP-I for the reduction of SSI rates. However, very low-quality evidence suggests that there is no significant difference between PVP-I alcohol-based solutions and PVP-I aqueous solutions. Several guidelines, such as those published by SHEA/IDSA 2014, NICE 2008 and 2013, recommend the use of an alcohol-based solution for surgical site preparation. However, these recommendations are not based on systematic reviews of the literature and meta-analysis or a rigorous evaluation of the quality of the available evidence.

Surgical hand preparation

WHO: The panel recommends that surgical hand preparation be performed either by scrubbing with a suitable antimicrobial soap and water or using a suitable ABHR before donning sterile gloves (Strong recommendation, moderate quality of evidence).

The Indian group of panelists agreed that the evidence is weak on alcohol-based hand scrub. Ambiguity exists about 'time to scrub', cleaning of nails, how to clean and how long to clean and subsequent gloving. The WHO guidelines on hand hygiene in health care is to be followed. Using the closed gloving technique, by a nurse gloving assistant, was considered to be appropriate. The use of liquid soap for scrubbing is encouraged.[14]

Summary of evidence

Only six studies comprising 3 RCTs[97],[98],[99] and three observational studies[100],[101],[102] were identified with SSI as the primary outcome. All studies compared hand rubbing to hand scrubbing for surgical hand preparation. Hand rubbing was performed using either Sterilium®, the WHO recommended formulation II, Avagard® or Purell®. Hand scrubbing products contained either CHG or PVP-I and/or plain soap. Five studies compared ABHR to hand scrubbing with an antimicrobial soap containing either PVP-I 4% or CHG 4% and showed no significant difference in SSI. The same result was found in a cluster randomised cross-over trial comparing ABHR to hand scrubbing with plain soap.[98] Evidence from RCTs with only a SSI outcome was considered for the development of the recommendation, which is rated as moderate due to inconsistency. The overall evidence shows that no difference between hand rubbing and hand scrubbing in reducing SSI.

  Pre-Operative And/or Intraoperative Measures Top

Use of protocols for intensive perioperative blood glucose control

WHO: The panel suggests the use of protocols for intensive perioperative blood glucose control for both diabetic and non-diabetic adult patients undergoing surgical procedures to reduce the risk of SSI (Conditional recommendation, low quality of evidence).

The Indian group of panelists recommended perioperative blood glucose levels be maintained at <200 mg/dL. An HBA1c of 7%—8% or less was agreed on as being optimal although evidence remains inadequate. The stricter maintenance of blood glucose lacks evidence in its effect of prevention of SSI. It was observed that in cardiac surgery, insulin is usually administered to achieve optimal perioperative glucose levels. The available evidence does not allow the definition of an optimal target level of blood glucose level.[14]

Summary of evidence

Fifteen RCTs[103],[104],[105],[106],[107],[108],[109],[110],[111],[112],[113],[114],[115],[116],[117] including a total of 2836 patients and comparing intensive perioperative blood glucose protocols compared with conventional protocols with less stringent blood glucose target levels were identified. Eight studies were performed in adult patients undergoing cardiac surgery,[6],[103],[104],[106],[108],[111],[112],[113],[117] in patients undergoing abdominal or major noncardiac surgery,[105],[107],[109],[114],[115],[116] and one other study in patients undergoing emergency cerebral aneurysm clipping.[110] No study was available in a paediatric population. In two studies,[106],[109] glucose control was performed intraoperatively only. Eight studies[103],[104],[108],[110],[112],[114],[116],[117] investigated intra-and post-operative glucose control and five studies[105],[107],[112],[114],[116] focused on post-operative glucose control. None of the studies had SSI as their primary outcome. Overall, there is low-quality evidence that a protocol with more strict blood glucose target levels has a significant benefit in reducing SSI rates when compared to a conventional protocol. Overall, there is an increased risk for hypoglycemic events with the use of either intensive protocol for blood glucose control.

Incisional wound irrigation

WHO: The panel considers that there is insufficient evidence to recommend for or against saline irrigation of incisional wounds before closure for preventing SSI. The panel suggests considering the use of irrigation of the incisional wound with an aqueous PVP-I solution before closure for the purpose of preventing SSI, particularly in clean and clean-contaminated wounds. The panel suggests that antibiotic incisional wound irrigation before closure should not be used for the purpose of preventing SSI (Conditional recommendations/low quality of evidence).

The Indian panelists deliberated the usefulness of incisional (saline) wound irrigation. Few of them believed wound irrigation does not reduce the risk of SSI. They were also of the view that if irrigation were undertaken then antiseptics should be encouraged and not antibiotics. For wound reexploration irrigation with PVP-I or/and CHG could be used. However, in case of irrigation/removal of debris, use of vancomycin was suggested but certainly not universally agreed. One of the panelists shared that they had used antibiotic bone cement but with no clear benefit.[14]

Summary of evidence

The available evidence from 7 RCTs[118],[119],[120],[121],[122],[123],[124] (10 estimates) showed that irrigation of the incisional wound with an aqueous PVP-I solution was beneficial in reducing the risk of SSI when compared to irrigation with a saline solution. Stratification of the evidence by contamination showed that the effect was attributable to incisional wound irrigation in clean and clean-contaminated procedures rated as wound Classes I and II according to the CDC system.[125] The available evidence from five RCTs shows that the antibiotic irrigation of the incisional wound has neither benefit nor harm in reducing SSI when compared to no or saline solution irrigation.

Antibacterial-coated sutures

WHO: The panel suggests the use of triclosan-coated sutures for the purpose of reducing the risk of SSI, independent of the type of surgery (Conditional recommendation, moderate quality of evidence).

The Indian panelists deliberated on the difference between applying antiseptics to the wound and the use of triclosan-coated/impregnated sutures. Formation and subsequent consequences of bio-film around suture material were discussed in conjunction of use if triclosan-coated suture and its benefits were evaluated. There was affirmation of use and requirement of triclosan-coated/impregnated sutures in Indian healthcare o however concerns over AMR was shared, although poorly justified.[14]

Summary of evidence

Eighteen studies (13 RCTs) and five cohort studies including a total of 7458 patients (RCTs, 5346; observational studies, 2112) and comparing the use of antimicrobial with non-coated sutures were identified. Included studies were performed in high-and middle-income countries. Types of surgical procedures included were colorectal, abdominal, breast, head and neck, lower limb, spinal, cardiac, vascular and other surgery. The types of sutures investigated in the included studies were triclosan-coated polydioxanone suture versus polydioxanone suture featuring a monofilament suture construction (3 RCTs[126],[127],[128]); triclosan-coated polyglactin 910 suture versus. polyglactin 910 suture featuring a braided (multifilament) suture construction (7 RCTs[129],[130],[131],[132],[133],[134],[135] and 4 observational studies[136],[137],[138],[139]); and polyglactin 910 and poliglecaprone 25 (both triclosan-coated) sutures versus polyglactin 910 and poliglecaprone 25 sutures featuring a braided (polyglactin 910) and a monofilament (poliglecaprone 25) suture construction (3RCTs[140],[141],[142] and one observational study.[143] No adverse events have been associated in the included studies with the use of antimicrobial-coated sutures.[140],[141],[142],[143],[144] However, evidence pointed out that there is limited evidence that triclosan may have negative effects on wound healing[145] or lead to contact allergy.[146] Although the development of resistance is mentioned as a concern, the daily absorption of triclosan from consumer products (for example, commercially-available hand soap) is higher than a single triclosan suture.[146],[147],[148] Overall, there is moderate-to-low quality evidence that antimicrobial-coated sutures have significant benefit in reducing SSI rates in patients undergoing surgical procedures when compared to non-coated sutures. Per these analyses, the effect seems to be independent of the type of suture, procedure or wound contamination classification.

  Post-Operative Measures Top

Surgical antibiotic prophylaxis prolongation

WHO: The panel recommends against the prolongation of SAP administration after completion of the operation for the purpose of preventing SSI (Strong recommendation/moderate quality of evidence).

The Indian panel deliberated on this and reached a consensus to not abuse antibiotic use. They believed a surgeon should judiciously administer antibiotic after considering patient characteristics, type of surgery and other risks for infection. For example, it was considered to be advisable to prolong SAP administration in a diabetic patient with implant and/or drain or cardiac valve.[14]

Summary of evidence

No recommendation could be concluded on the benefit or harm of this approach. For cardiac (2 RCTs)[149],[150] and orthognathic surgery (3 RCTs),[151],[152],[153] there was some evidence that prolonging antibiotic administration after completion of the operation may be beneficial in reducing the risk of SSI when compared to single-dose prophylaxis. By contrast, other RCTs[154],[155],[156],[157],[158],[159],[160] showed no benefit of prolonging antibiotic prophylaxis beyond 24 h compared to prophylaxis for up to 24 h in these types of surgery. In vascular surgery, there was some evidence from one RCT[161] that prolonging antibiotic prophylaxis until intravenous lines and tubes are removed may be beneficial in reducing the risk of SSI when compared to single-dose prophylaxis.

Antimicrobial prophylaxis in the presence of a drain and optimal timing for wound drain removal

WHO: The panel suggests that perioperative antibiotic prophylaxis should not be continued to the presence of a wound drain for the purpose of preventing SSI (Conditional recommendation, low quality of evidence). The panel suggests removing the wound drain when clinically indicated. No evidence was found to recommend an optimal timing of wound drain removal for the purpose of preventing SSI (Conditional recommendation, very low quality of evidence).

The Indian panelists deliberated and accepted the above WHO recommendation. They added that the use of antibiotics when a drain is present may be at discretion of surgeon on situational basis.

Summary of evidence

Seven RCTs[161],[162],[163],[164],[165],[166],[167] were identified. They included a total of 1670 patients and investigated whether antibiotics should be administered pre-operatively as a single dose and possibly re-dosed according to the duration of the operation or if their administration should be extended to the post-operative period. Three studies reported a prolonged antibiotic administration until the wound drain was removed. In the remaining four trials, patients received a 3-day[163],[167] or 5-day intravenous course.[166] Patients enroled in the studies underwent general surgery,[161],[163],[167] kidney transplantation[164] and pilonidal sinus surgery.[166] One trial[165] determined whether prolonged antibiotic prophylaxis reduced the risk of infectious complications for patients undergoing elective thoracic surgery with tube thoracostomy. The antibiotic was continued for 48 h after the procedure or until all thoracostomy tubes were removed, whichever came first. There is low-quality evidence that prolonged antibiotic prophylaxis in the presence of a wound drain has neither benefit nor harm in reducing SSI when compared to perioperative prophylaxis alone. Nine studies investigated the duration of drains in patients undergoing mastectomy[168],[169],[170],[171],[172],[173],[174],[175],[176] and two studies after hip or knee arthroplasty.[177],[178] One trial[178] compared three different time points of drain removal (12 h, 24 h and 48 h). There is very low-quality evidence that the early removal of wound drains has neither benefit nor harm in reducing the SSI rate when compared to late removal.

Panelists also considered and evaluated other recommendations from the WHO guidelines. However, considering the diverse healthcare set up across India, those are not included in this framework. These guidelines are the must doable and most doable action items that HCP can practice to bring down the mortality and morbidity in patients due to SSI/HAI.

Grade categories for the quality of evidence


We are very confident that the true effect lies close to that of the estimate of the effect.[1]


We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect; however, there is a possibility that it is substantially different.


Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.

Very low

We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of the effect. The strength of recommendations was rated as follows:


The panel was confident that the benefits of the intervention outweighed the risks.


The panel considered that the benefits of the intervention probably outweighed the risks.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

WHO document on Global Guidelines For the Prevention of Surgical Site Infection. WHO Guidelines Development Group; Geneva, Switzerland; 2016;58-177.  Back to cited text no. 1
Kamat US, Fereirra AM, Kulkarni MS, Motghare DD. A prospective study of surgical site infections in a teaching hospital in Goa. Indian J Surg 2008;70:120-4.  Back to cited text no. 2
Bhatia JY, Pandey K, Rodrigues C, Mehta A, Joshi VR. Postoperative wound infection in patients undergoing coronary artery bypass graft surgery: A prospective study with evaluation of risk factors. Indian J Med Microbiol 2003;21:246-51.  Back to cited text no. 3
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