New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective

Abstract

Surgical site infections (SSIs) are the most common health-care-associated infections in developing countries, but they also represent a substantial epidemiological burden in high-income countries. The prevention of these infections is complex and requires the integration of a range of preventive measures before, during, and after surgery. No international guidelines are available and inconsistencies in the interpretation of evidence and recommendations in national guidelines have been identified. Considering the prevention of SSIs as a priority for patient safety, WHO has developed evidence-based and expert consensus-based recommendations on the basis of an extensive list of preventive measures. We present in this Review 16 recommendations specific to the intraoperative and postoperative periods. The WHO recommendations were developed with a global perspective and they take into account the balance between benefits and harms, the evidence quality level, cost and resource use implications, and patient values and preferences.

WHO Needs High FIO2?

“…The guidelines recently published by the World Health Organization (21) and the United States Center for Disease Control (8) recommend the use of 0.8 FIO 2 in all adult surgical patients undergoing general anaesthesia. The rationale for 80% inspired oxygen intraoperatively and also for 2 to 6 hours postoperatively is to decrease the risk of surgical site infection (SSI).…”

“…The world health organization (WHO) presented guidelines recommending the use of hyperoxic gas (80% O 2 ) during anesthesia and, if feasible, for 2-6 hours post operatively (21). One can argue against these guidelines, perhaps for several reasons, but I will limit my critical attitude to two issues.…”

“…However, studies investigating the use of different FIO 2 levels should comprise several end-points, to reflect the complexity of the effects of oxygen on different organs' function. The guidelines recently published on behalf of the WHO Guidelines Development Group, (21) recommend the use of 0.8 FIO 2 in the whole intra-and post-operative period in all surgical patients to reduce the incidence of SSIs. This recommendation, that the WHO grades as 'strong' and based on 'moderate' evidence quality, received criticisms from researchers in anaesthesiology (22,23).…”

The WHO recommendation for 80% perioperative oxygen is poorly justified

“…We and the WHO panellists recognize that "ventilation control (and therefore the actual administration of FiO2) with a face mask or nasal cannulae in neuraxial anaesthesia (differs) from mechanical ventilation" [1]. But to the extent that increased FiO2 protects against wound infection, it should also do so during regional anaesthesia (for example in caesarean deliveries).…”

Quality, cost and outcomes measures in orthopaedic healthcare

“…The recently published WHO recommendations on pre-, intraand post-operative methods for surgical site infection prevention represent a superb effort to serve such a population [4,5]. The aim is to highlight methods that may help reduce the two to 20 times higher prevalence of health-care associated infections of which surgical site infections are the most common in LMIC [6,7].…”