Aorn journal preoperative hair removal

Back to Basics: Preventing Surgical Site Infections LISA SPRUCE, DNP, RN, ACNS, ACNP, ANP, CNOR 1.5

www.aorn.org/CE

ABSTRACT

A surgical site infection (SSI) is an unintended and oftentimes preventable

consequence of surgery. There is a significant amount of literature related to

preventing SSIs, and it is up to practitioners in each care setting to review the

evidence and work together to implement SSI prevention measures, such as nasal

decolonization, antibiotic prophylaxis, preoperative showers, preoperative oxy-

gen supplementation, and antimicrobial sutures. In addition, practitioners can

follow several recommendations to reduce the risk of SSIs, including following

proper hand hygiene practices; wearing clean, facility-laundered scrub attire;

following a surgical safety checklist; and speaking up when a break in sterile

technique is witnessed. The benefits of preventing SSIs are preventing patient

mortality and decreasing the burden that SSIs pose on the national health care

system. It is up to health care leaders to drive and support SSI prevention ini-

tiatives. AORN J 99 (May 2014) 601-608. � AORN, Inc, 2014. http://dx.doi.org/ 10.1016/j.aorn.2014.02.002

Key words: surgical site infection, SSI, health careeassociated infection, HAI.

H ealth careeassociated infections (HAIs) are

infections acquired by patients while they

are receiving treatment in a health care

setting, and surgical site infections (SSIs) are an

unintended consequence of surgery. The Centers for

Disease Control and Prevention (CDC) defines an

SSI as “an infection that occurs after surgery in the

part of the body where the surgery took place.” 1

Surgical site infections are the second most common

HAI that occurs in hospitalized patients; they result

in an increase in costs, readmission rates, lengths of

stay, and patient mortality, and it is estimated that

40% to 60% of these infections are preventable. 2

The annual direct cost of HAIs to the US health care

system ranges from $28.4 billion to $45 billion. 3

Preventing SSIs is a national priority. Bacteria

are becoming increasingly resistant to antibiotics,

making SSI prevention even more important to-

day. In the past several years, there has been an

increased focus on SSI prevention in the ambula-

tory setting. Recognizing the increase in proce-

dures and treatments being conducted in an outpatient

setting, the CDC created a guide to infection pre-

vention for the ambulatory setting 4 that can be

accessed online. Guides for SSI prevention in the

inpatient setting are also available online. 5 There

has been a wealth of evidence published on the

topic of SSI prevention, and this “Back to Basics”

article will review recent evidence and discuss

the actions that perioperative team members can

http://dx.doi.org/10.1016/j.aorn.2014.02.002

� AORN, Inc, 2014 May 2014 Vol 99 No 5 � AORN Journal j 601

http://www.aornjournal.org
http://dx.doi.org/10.1016/j.aorn.2014.02.002
take to prevent SSIs and keep patients safe

from harm.

LITERATURE REVIEW

There is a significant amount of literature related

to preventing SSIs. Many articles and reviews

show a clear benefit of certain interventions, while

others are more suggestive of potential benefits or

fail to demonstrate a proven benefit. It is up to

practitioners in each care setting to review the

evidence and work together to implement practices

aimed at ensuring the safety of the patients in their

individual settings. To follow is an overview of

some of the available literature related to prevent-

ing SSIs.

In August 2013, the Cochrane Library published

a special collection focusing on systematic reviews

related to infection prevention. 6 The following infor-

mation from the review is related to perioperative

SSI prevention interventions.

n Nasal decolonization. Use of intranasal mupir-

ocin ointment for Staphylococcus aureus decol-

onization resulted in a statistically significant

reduction of S aureus SSIs. 7

n Preoperative showers. Research has shown

no clear evidence of benefit for preoperative

showering or bathing with chlorhexidine glu-

conate (CHG) compared with other products to

reduce SSIs. 8

n Antibiotic prophylaxis. Care providers should

administer antibiotics to patients who are under-

going colorectal surgery and to those who are

undergoing closed fracture fixation to reduce the

risk of SSIs. 9,10

Prophylaxis also is effective in

the prevention of postoperative complications

in patients who are undergoing appendectomy

regardless of whether health care providers

administered the antibiotic before, during, or

after surgery. 11

n IV antibiotics. Administering IV antibiotics

before percutaneous endoscopic gastrostomy

tube placement decreases the risk of infection at

the insertion site. 12

n Adhesive drapes. There is no evidence that

adhesive drapes reduce SSIs, and there is some

evidence that their use intraoperatively may

increase SSI rates. 13

n Glycemic control. Insufficient evidence exists

to determine whether strict glycemic control

intraoperatively is superior to conventional

glycemic control for reducing SSIs. 14

The National Institute for Health and Care

Excellence (NICE) completed an evidence update

for its SSI guideline in June 2013. 15

The evidence

summary in the following text discusses the findings.

n Preoperative showers. Three studies 8,16,17

indicated that there are uncertain benefits from

showering or bathing preoperatively with any

Figure 1. There is nothing wrong with this picture. By discussing patient-specific measures for prevention of surgical site infection in a preprocedure huddle, perioperative team members can improve the quality of care, hold one another accountable, and be empowered to speak up.

602 j AORN Journal

May 2014 Vol 99 No 5 SPRUCE

product. Evidence regarding the most effective

type of antiseptic to use is also inconclusive.

Despite this, the NICE update recommends

that patients shower or bathe with soap before

surgery to reduce bacterial levels on the skin,

but there is no conclusive evidence that this

reduces SSIs.

n Hair removal. A Cochrane Database review 18

concluded that the evidence for preoperative

hair removal is insufficient to draw conclusions

about its effects on SSIs. However, the NICE

update recommends that clipping should be

used if hair removal is deemed necessary before

surgery. No studies to date have researched

whether the preoperative or intraoperative

setting is the best setting for hair removal.

n Hand jewelry, artificial nails, and nail polish.

There is a lack of evidence to determine whether

removing rings and nail polish preoperatively

has an effect on SSIs. 19

Despite this, the NICE

update recommends that personnel remove hand

jewelry and nail polish if working in the OR

setting.

n Antibiotic prophylaxis. A systematic review

and meta-analysis 20

suggest that use of a pro-

phylactic antibiotic and antiseptic skin prep-

aration reduces the risk of SSIs in patients

undergoing cardiac device implantation. The

NICE update recommends prophylactic anti-

biotics and antiseptic skin preparation for

any patient undergoing a clean surgery with

an implant. A Cochrane review 21

suggests that

using a prophylactic antibiotic for patients

undergoing hernia repair with mesh reduces the

risk of SSIs; however, prophylactic antibiotics

did not reduce the risk of SSIs when mesh

was not used. Akinyoola et al 22

conducted one

randomized controlled trial in Nigeria that

suggested that administering antibiotics after

tourniquet inflation rather than before inflation

resulted in a decrease in SSIs. A 2012 Cochrane

review and a 2013 randomized controlled trial

collectively suggest that prophylactic antibiotics

may reduce the risk of SSIs during breast cancer

surgery. 23,24

However, the NICE update does

not recommend antibiotic prophylaxis in clean,

nonprosthetic surgery, and when making this

recommendation theyconsidered cost,medication

reactions, and antimicrobial resistance. 15 The

NICE update did not change its recommendation

to administer antibiotics before tourniquet infla-

tion if a tourniquet is used. The NICE update

recommendsprophylacticantibioticadministration

for any clean surgery with an implant.

n Surgical face masks. The NICE update does

not make a specific recommendation regarding

the wearing of surgical masks for SSI preven-

tion. However, there are other reasons for

wearing a surgical mask than SSI prevention;

most significantly, masks are used as perso-

nal protective equipment. 15

A 2012 Cochrane

review 25

identified three studies that compared

infection rates between personnel wearing and

not wearing a surgical mask during a clean

surgical procedure; in all three studies, there

was no significant effect on infection rates

between these personnel. 25

n Antiseptic skin preparation. Two reviews 25,26

recently compared several different types of

skin preparations in the prevention of SSIs.

These reviews collectively concluded that there

was insufficient evidence to determine the most

effective skin preparation agent to use before

making a surgical incision. 25,26

The NICE up-

date recommends using either povidone-iodine

or CHG solutions with or without alcohol.

n Diathermy. A Cochrane review 27

compared the

use of a scalpel with an electrocautery device to

make an incision on the risk of SSIs and showed

that there is no advantage of using electrocautery

over a scalpel to prevent SSIs. 27 The NICE update

recommends that diathermy should not be used to

make an incision to reduce the risk of SSIs.

n Perioperative oxygen supplementation. A 2012

systematic review with meta-analysis 28 concluded

that it was unlikely that perioperative oxygen

supplementation reduced SSI rates; however,

there may be some subgroups of patients who

AORN Journal j 603

BACK TO BASICS: SSI PREVENTION www.aornjournal.org

http://www.aornjournal.org
would benefit. The NICE update recommends

maintaining optimal oxygenation during surgery.

In particular, patients should be given sufficient

oxygen during major surgery and in the recovery

period to ensure that the patient maintains a

hemoglobin saturation of more than 95%.

n Hemodynamic goal-directed therapy. Dalfino

et al 29

researched “haemodynamic treatment

based on titration of fluid and inotropic drugs

infused to physiologic flow-related end points”

and concluded that maintaining hemodynamic

control appears to reduce the risk of SSI. The

NICE update recommends maintaining optimal

oxygenation and adequate perfusion during

surgery.

n Wounddressings.ACochranereview 30 compared

wound dressings for the prevention of SSIs and

concluded there was no evidence that covering

wounds versus keeping them uncovered reduced

SSI rates. 30 The NICE update recommends

covering surgical incisions with an appropriate

dressing at the end of the operation. However,

it does not make any recommendations about

specific types of dressings.

n Wound closure methods. A Cochrane review 31

examined SSI rates after the use of sutures

or staples. There was no significant difference

between the use of sutures and staples; however,

the review only looked at SSI rates in vein har-

vesting closure for coronary artery bypass grafting

procedures. 31

The NICE update does not make a

recommendation for wound closure method.

n Antimicrobial sutures. A 2013 systematic re-

view with meta-analysis 32 looked at randomized

controlled trials comparing sutures coated with

triclosanwith uncoatedsuturesandfound that use

of the triclosan-coated sutures reduced infection

rates. A second review performed in 2013 by

Edmiston et al 33 reached the same conclusion as

the first review; therefore, the collective evidence

suggests a benefit for reducing SSI risk by using

antimicrobial-coated sutures. The NICE did not

update this recommendation but is continuing to

review the evidence.

n Minimally invasive surgery. Two systematic

reviews in 2012 looked at SSI rates among

obese patients undergoing laparoscopic surgical

procedures. 34,35

The collective evidence sug-

gests that laparoscopy appears to be associated

with lower SSI rates among obese patients and

those undergoing colorectal surgery. 34,35

The

NICE update does not make any recommenda-

tions about the use of minimally invasive sur-

gery in preventing SSIs.

HOW-TO GUIDE

Surgical site infections can be prevented by fol-

lowing these relatively simple recommendations.

Personnel should

n clean their hands often with an alcohol-based

product and perform appropriate surgical hand

scrubs,

n perform surgical skin antisepsis using an ap-

propriate technique and antiseptic,

n wear clean, facility-laundered scrub attire,

n minimize OR traffic,

n follow environmental cleaning protocols,

n engage with a patient who has experienced an

SSI or the patient’s family member to develop

SSI prevention strategies, 36

n follow a surgical safety checklist,

n implement team training to promote a team-

based approach to SSI prevention,

n minimize the use of immediate use steam

sterilization, 36

n clean instruments thoroughly before sterilizing

or disinfecting, and

n speak up whenever a break in sterile technique

is witnessed and correct the break as soon as

possible.

BENEFITS

Patients undergo surgery expecting improvement

in their overall health, relief from pain, or cure

from disease. They do not expect to experience

the devastating consequences of an SSI. Surgical

site infections represent a significant burden to

604 j AORN Journal

May 2014 Vol 99 No 5 SPRUCE

the health care system and

contribute to patient mortal-

ity. The estimated cost of

SSIs to hospitals is $7.4

billion with 13,088 deaths

per year. More than 290,000

infections are estimated to

occur annually, and the

cost of treatment averages

slightly more than $25,000

per infection. 36

The clear

benefits of preventing SSIs

shown in these statistics are

preventing patient mortality

and decreasing the burden

that SSIs pose on the na-

tional health care system.

TIPS & TRICKS

Integrating all this informa-

tion into an initiative to pre-

vent SSIs can be daunting,

but the implementation of

an improvement initiative

should begin with facility

leaders and requires re-

sources. Leaders drive, plan,

and implement any initia-

tive; to do this, leaders

should gather a multidisci-

plinary team to set goals,

establish performance mea-

sures, test and study the

initiatives, and continually

improve SSI prevention

processes. The Institute for

Healthcare Improvement

has published a “How-to

Guide” for the prevention

of SSIs, and the follow-

ing information highlights

some of the steps needed

to implement this type of

intiative. 37

Resources for Surgical Site Infection Prevention

n Bioburden on surgical instruments. Pa Patient Saf Advis.

2006;3(1):20-24. http://patientsafetyauthority.org/ADVISORIES/

AdvisoryLibrary/2006/Mar3(1)/Pages/20.aspx.

n Bradley S. Strategies to fully implement infection control

practices in Pennsylvania ambulatory surgical facilities. Pa

Patient Saf Advis. 2013;10(3):99-106. http://patientsafetyauthority

.org/ADVISORIES/AdvisoryLibrary/2013/Sep;10(3)/Pages/99.

aspx.

n Guide to Infection Prevention in Outpatient Settings: Minimum

Expectations for Safe Care. Atlanta, GA: Centers for Disease

Control and Prevention; 2011. http://www.cdc.gov/hai/pdfs/

guidelines/ambulatory-care-04-2011.pdf.

n Guideline for Prevention of Surgical Site Infection, 1999.

Atlanta, GA: Centers for Disease Control and Prevention; 1999.

http://www.cdc.gov/hicpac/SSI/001_SSI.html.

n How-to Guide: Prevent Surgical Site Infections. Cambridge,

MA: Institute for Healthcare Improvement; 2012. http://www.ihi

.org/knowledge/Pages/Tools/HowtoGuidePreventSurgicalSite

Infection.aspx.

n Joint Commission Implementation Guide for NPSG.07.05.01 on

Surgical Site Infections: The SSI Change Project. Oakbrook

Terrace, IL: The Joint Commission; 2013. http://www.joint

commission.org/assets/1/18/Implementation_Guide_for_NPSG_

SSI.pdf.

n Prevent Surgical Site Infections: Getting Started Kit. Edmonton,

AB, Canada: Canadian Patient Safety Institute; 2011. http://

www.saferhealthcarenow.ca/EN/Interventions/SSI/Documents/

SSI%20Getting%20Started%20Kit.pdf.

n Recommended practices for the prevention of transmissible

infections. In: Perioperative Standards and Recommended

Practices. Denver, CO: AORN, Inc; 2014:385-420.

n Surgical site infection (CG74). National Institute for Health and

Care Excellence; 2008. http://www.nice.org.uk/CG74.

n Surgical Site Infections (SSI) Toolkit: A Provider’s Guide to

Preventing Surgical Site Infections. Oklahoma Foundation for

Medical Quality and Stratis Health, the National Coordinating

Center (NCC) for Improving Individual Patient Care (IIPC)

Aim; Centers for Medicare & Medicaid Services. http://www

.masspro.org/files/tools/ssitool112012.pdf.

Web access verified January 30, 2014.

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BACK TO BASICS: SSI PREVENTION www.aornjournal.org

http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2006/Mar3(1)/Pages/20.aspx
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2006/Mar3(1)/Pages/20.aspx
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2013/Sep;10(3)/Pages/99.aspx
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2013/Sep;10(3)/Pages/99.aspx
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2013/Sep;10(3)/Pages/99.aspx
http://www.cdc.gov/hai/pdfs/guidelines/ambulatory-care-04-2011.pdf
http://www.cdc.gov/hai/pdfs/guidelines/ambulatory-care-04-2011.pdf
http://www.cdc.gov/hicpac/SSI/001_SSI.html
http://www.ihi.org/knowledge/Pages/Tools/HowtoGuidePreventSurgicalSiteInfection.aspx
http://www.ihi.org/knowledge/Pages/Tools/HowtoGuidePreventSurgicalSiteInfection.aspx
http://www.ihi.org/knowledge/Pages/Tools/HowtoGuidePreventSurgicalSiteInfection.aspx
http://www.jointcommission.org/assets/1/18/Implementation_Guide_for_NPSG_SSI.pdf
http://www.jointcommission.org/assets/1/18/Implementation_Guide_for_NPSG_SSI.pdf
http://www.jointcommission.org/assets/1/18/Implementation_Guide_for_NPSG_SSI.pdf
http://www.saferhealthcarenow.ca/EN/Interventions/SSI/Documents/SSI%20Getting%20Started%20Kit.pdf
http://www.saferhealthcarenow.ca/EN/Interventions/SSI/Documents/SSI%20Getting%20Started%20Kit.pdf
http://www.saferhealthcarenow.ca/EN/Interventions/SSI/Documents/SSI%20Getting%20Started%20Kit.pdf
http://www.nice.org.uk/CG74
http://www.masspro.org/files/tools/ssitool112012.pdf
http://www.masspro.org/files/tools/ssitool112012.pdf
http://www.aornjournal.org
n Appropriate use of antibiotics. Team mem-

bers should standardize their protocol using

national guidelines, only use preprinted or

computerized standing orders, verify adminis-

tration during time-out processes, and have the

preoperative nurse or anesthesia professional

assign dosing responsibilities.

n Appropriate hair removal. Team members

should remove all razors from the facility, in-

struct patients not to use a razor before surgery,

ensure that clippers are readily available, and

educate personnel by using posters and printed

material.

n Glucose control in cardiac patients. Team

membersshouldimplementoneprotocol,checkthe

patient’s glucose level preoperatively, and assign

responsibility for monitoring glucose control.

n Perioperative normothermia in patients un-

dergoing colorectal surgery. Team members

should proactively prevent hypothermia during

all phases of perioperative care by using forced-

air warming and warmed fluids, placing warming

blankets under patients, having patients don hats

and booties preoperatively, and maintaining

rooms at a steady temperature, even overnight.

The Joint Commission implementation guide on

the prevention of SSIs 38

recommends focused prac-

titioner activities that can be highly valuable when

planning a how-to guide. The following are recom-

mendations from The Joint Commission:

n The whole perioperative department should

accept responsibility and accountability for

their actions to prevent SSIs.

n Surgeons and other physicians should be closely

involved in SSI prevention initiatives, and

champions should be identified.

n Anesthesia professionals should administer

prophylactic antibiotics.

n Facility educators or infection prevention per-

sonnel should provide multidisciplinary educa-

tion on SSI prevention, and all team members,

including surgeons and anesthesia professionals,

should participate.

n Personnel should follow preoperative and post-

operative order sets.

n Personnel should keep traffic in the OR to a

minimum.

n Assigned personnel should conduct direct

observation of infection prevention practices

and provide immediate feedback to staff

members.

n Personnel should stay current on the latest SSI

prevention evidence and make practice changes

when needed.

WRAP-UP

This “Back to Basics” article is not an exhaustive

search of the literature regarding SSIs, but it is a

review of the recent evidence that surrounds SSI

prevention. It is important for perioperative nurses

to stay current regarding SSI prevention strategies

because new evidence and research emerges daily.

Every perioperative professional must be accou-

ntable not only for his or her own actions but for

the actions of the entire team. Speaking up and

pointing out that a colleague forgot to wash his or

her hands, identifying a break in sterile technique,

or notifying the surgical team that surgical instru-

ments were not adequately cleaned may seem

like small issues, but not acknowledging them

could mean the difference between life and death

for a patient. Addressing SSI prevention issues in

a preprocedure huddle as a team is a great way

to improve the quality of care, hold one another

accountable, and be empowered to speak up. Sur-

gical site infections are preventable, and prevention

of SSIs is a fundamental basic of perioperative

nursing.

References 1. Surgical site infection. Centers for Disease Control and

Prevention. 2010. http://www.cdc.gov/HAI/ssi/ssi.html.

Accessed January 16, 2014.

2. Preventing health care and community associated in-

fections. Safe Care Campaign. http://www.safecare

campaign.org/ssi.html. Accessed January 30, 2014.

3. Douglas S. Direct medical costs of healthcare-associated

infections in U.S. hospitals and the benefits of prevention.

Centers for Disease Control and Prevention. http://

606 j AORN Journal

May 2014 Vol 99 No 5 SPRUCE

http://www.cdc.gov/HAI/ssi/ssi.html
http://www.safecarecampaign.org/ssi.html
http://www.safecarecampaign.org/ssi.html
http://www.cdc.gov/hai/pdfs/hai/scott_costpaper.pdf
www.cdc.gov/hai/pdfs/hai/scott_costpaper.pdf. 2009.

Accessed January 16, 2014.

4. Guide to infection prevention for outpatient settings:

minimum expectations for safe care. Centers for Disease

Control and Prevention, National Center for Emerging

and Zoonotic Infectious Diseases. 2011. http://www.cdc

.gov/HAI/pdfs/guidelines/standatds-of-ambulatory-care

-7-2011.pdf. Accessed January 16, 2014.

5. Healthcare associated infections: surgical site infections.

Centers for Disease Control and Prevention. http://www

.cdc.gov/HAI/ssi/ssi.html. Accessed February 3, 2014.

6. Hospital-acquired infection. The Cochrane Library. 2013.

http://www.thecochranelibrary.com/details/collection/

5163721/Hospital-acquired-infection.html. Accessed

January 16, 2014.

7. van Rijen M, Bonten M, Wenzel R, Kluytmans J. Mupir-

ocin ointment for preventing Staphylococcus aureus

infections in nasal carriers. Cochrane Database Syst

Rev. 2008;(4):CD006216.

8. Webster J, Osborne S. Preoperative bathing or showering

with skin antiseptics to prevent surgical site infection.

Cochrane Database Syst Rev. 2012;(9):CD004985.

9. Nelson RL, Glenny AM, Song F. Antimicrobial pro-

phylaxis for colorectal surgery. Cochrane Database

Syst Rev. 2009;(1):CD001181.

10. Gillespie WJ, Walenkamp GHIM. Antibiotic prophylaxis

for surgery for proximal femoral and other closed long

bone fractures. Cochrane Database Syst Rev. 2010;(3):

CD000244.

11. Andersen BR, Kallehave FL, Andersen HK. Antibiotics

versus placebo for prevention of postoperative infection

after appendicectomy. Cochrane Database Syst Rev.

2005;(3):CD001439.

12. Lipp A, Lusardi G. Systemic antimicrobial prophylaxis

for percutaneous endoscopic gastrostomy. Cochrane

Database Syst Rev. 2006;(4):CD005571.

13. Webster J, Alghamdi A. Use of plastic adhesive

drapes during surgery for preventing surgical site

infection. Cochrane Database Syst Rev. 2013;(1):

CD006353.

14. Kao LS, Meeks D, Moyer VA, Lally KP. Peri-operative

glycaemic control regimens for preventing surgical site

infections in adults. Cochrane Database Syst Rev. 2009;

(3):CD006806.

15. Surgical site infection: evidence update June 2013.

Natl Inst Health Care Excellence. 2013;43:1-28; 2013.

https://www.evidence.nhs.uk/evidence-update-43.

Accessed January 17, 2014.

16. Jakobsson J, Perlkvist A, Wann-Hansson C. Searching

for evidence regarding using preoperative disinfection

showers to prevent surgical site infections: a systematic

review. Worldviews Evidence-Based Nurs. 2011;8(3):

143-152.

17. Kamel C, McGahan L, Polisena J, Mierzwinski-Urban M,

Embil J. Preoperative skin antiseptic preparations for

preventing surgical site infections: a systematic re-

view. Infect Control Hosp Epidemiol. 2012;33(6):

608-617.

18. Tanner J, Norrie P, Melen K. Preoperative hair removal

to reduce surgical site infection. Cochrane Database Syst

Rev. 2011;(11):CD004122.

19. Arrowsmith VA, Taylor R. Removal of nail polish and

finger rings to prevent surgical infection. Cochrane

Database Syst Rev. 2012;(5):CD003325.

20. Darouiche R, Mosier M, Voigt J. Antibiotics and anti-

septics to prevent infection in cardiac rhythm management

device implantation surgery. Pacing Clin Electrophysiol.

2012;35(11):1348-1360.

21. Sanchez-Manuel FJ, Lozano-Garc�ıa J, Seco-Gil JL. Anti- biotic prophylaxis for hernia repair. Cochrane Database

Syst Rev. 2012;(2):CD003769.

22. Akinyoola AL, Adegbehingbe OO, Odunsi A. Timing of

antibiotic prophylaxis in tourniquet surgery. J Foot Ankle

Surg. 2011;50(4):374-376.

23. Bunn F, Jones DJ, Bell-Syer S. Prophylactic antibiotics to

prevent surgical site infection after breast cancer surgery.

Cochrane Database Syst Rev. 2012;(1):CD005360.

24. Cabaluna ND, Uy GB, Galicia RM, Cortez SC, Yray ND,

Buckley BS. A randomized, double-blinded placebo-

controlled clinical trial of the routine use of preoperative

antibiotic prophylaxis in modified radical mastectomy.

World J Surg. 2013;37(1):59-66.

25. Hadiati DR, Hakimi M, Nurdiati DS. Skin preparation

for preventing infection following caesarean section.

Cochrane Database Syst Rev. 2012;(9):CD007462.

26. Darouiche RO, Wall MJ Jr, Itani KM, et al. Chlorhexidine-

alcohol versus povidone-iodine for surgical-site antisepsis.

N Engl J Med. 2010;362(1):18-26.

27. Charoenkwan K, Chotirosniramit N, Rerkasem K. Scalpel

versus electrosurgery for abdominal incisions. Cochrane

Database Syst Rev. 2012;(6):CD005987.

28. Togioka B, Galvagno S, Sumida S, Murphy J, Ouanes JP,

Wu C. The role of perioperative high inspired oxygen

therapy in reducing surgical site infection: a meta-analysis.

Anesth Analg. 2012;114(2):334-342.

29. Dalfino L, Giglio MT, Puntillo F, Marucci M, Brienza N.

Haemodynamic goal-directed therapy and postoperative

infections: earlier is better. A systematic review and

meta-analysis. Crit Care. 2011;15(3):R154.

30. Dumville JC, Walter CJ, Sharp CA, Page T. Dressings

for the prevention of surgical site infection. Cochrane

Database Syst Rev. 2011;(7):CD003091.

31. Biancari F, Tiozzo V. Staples versus sutures for closing leg

wounds after vein graft harvesting for coronary arterybypass

surgery. Cochrane Database Syst Rev. 2010;(5):CD008057.

32. Wang ZX, Jiang CP, Cao Y, Ding YT. Systematic review

and meta-analysis of triclosan-coated sutures for the pre-

vention of surgical-site infection. Br J Surg. 2013;100(4):

465-473.

33. Edmiston CE Jr, Daoud FC, Leaper D. Is there an

evidence-based argument for embracing an antimicrobial

(triclosan)-coated suture technology to reduce the risk for

surgical-site infections? A meta-analysis. Surgery. 2013;

154(1):89-100.

34. Phatak UR, Pedroza C, Millas SG, Chang GJ, Lally KP,

Kao LS. Revisiting the effectiveness of interventions to

decrease surgical site infections in colorectal surgery:

a Bayesian perspective. Surgery. 2012;152(2):202-211.

35. Shabanzadeh DM, Sørensen LT. Laparoscopic surgery

compared with open surgery decreases surgical site

infection in obese patients: a systematic review and meta-

analysis. Ann Surg. 2012;256(6):934-945.