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Original Scientific Articles from the ACS Scientific Forum 2021: Invited Commentary

Effective and Evidence-Based Intervention Guidelines for Surgical Site Infection Prevention

Husain, Syed MD, FACS, FASCRS

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Journal of the American College of Surgeons: January 2022 - Volume 234 - Issue 1 - p 12-13
doi: 10.1097/XCS.0000000000000019
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I am truly honored and absolutely delighted for the opportunity to comment on “Delphi Consensus on Intraoperative Technical/Surgical Aspects to Prevent Surgical Site Infection after Colorectal Surgery” by Ruiz-Tovar and colleagues.1 This article attempts to address an extremely pertinent and very timely topic with practical, actionable recommendations for practicing surgeons. Given the inherently contaminated nature, colorectal operations carry a very high risk of surgical site infection (SSI). As one would expect, SSIs not only contribute to significant patient morbidity but also drive up healthcare delivery costs. According to one report, SSI cost almost $21,000 per incidence, with an overall burden of more than $3 billion annually.2

The authors present an expert consensus on 15 statements, each describing a specific intraoperative intervention aimed at mitigating SSI. A modified Delphi process was adapted, including up to 3 rounds per topic, with consensus threshold defined as 70% or greater agreement between the experts. Out of the 15 interventions scrutinized, insufficient evidence was found to endorse routine use of 9, whereas the remaining 6 interventions were deemed evidence-based. The latter included wound protector/retractor use, saline irrigation of high-risk contaminated wounds, separate closure tray, glove change before closure, antibiotic impregnated sutures, and negative pressure wound therapy for high-risk contaminated wounds. It is important to note that the presented consensus pertains to wound infection only; organ space infection was not addressed in this effort.

The emergence of enhanced recovery bundles has led to significant reduction in SSI. A protocolized approach to perioperative care not only promotes compliance but also fosters efficient implementation of enhanced recovery bundles. Because most of these bundles are comprised of multiple interventions implemented simultaneously in pre-, intra-, and postoperative phases of care, it is often difficult to quantify the impact of individual bundle components. Therefore, it comes as no surprise that very little objective data exist to help assess the risk mitigation attributable to individual protocol elements, making the current study even more pertinent.

Although there is a plethora of literature addressing SSI, I would like to draw the reader’s attention to 3 seminal publications: the WHO global guidelines for SSI prevention,3 the CDC guideline for prevention of SSI,4 and the Cochrane Review of intraoperative interventions to prevent SSI.5 The current study mirrors the findings of aforementioned publications. Despite the obvious similarities, there are several unique aspects worthy of special mention, setting the current study apart from earlier works. First, the subject matter is highly pertinent to surgeons, as it focuses exclusively on intraoperative interventions. SSI is frequently attributed to patient or disease-related factors, or, in the case of colorectal surgery, the contaminated nature of the procedure itself. This outsized contribution by nonmodifiable risk factors adds to the frustration experienced by surgeons when it comes to SSI. The current study empowers surgeons by highlighting modifiable and, more importantly, surgeon-led interventions. Second, the interventions highlighted by the authors are not only evidence-based but also extremely pragmatic. The relative simplicity makes these recommendations well-suited for easy implementation and rapid incorporation into any surgical practice regardless of the breadth of its scope. Furthermore, most highlighted interventions do not require significant capital, personnel, or infrastructure investment. Third, the consensus statements are constructed around topics extremely germane to contemporary surgical practice. Topic selection was undertaken in the first round of the Delphi process, and its aptness is a testament to the robust scientific process employed by the authors. Practicing surgeons regularly grapple with SSI mitigation efforts addressed in this study, and there is very little hard evidence to support or debunk any of these interventions. Therefore, it is extremely valuable to generate expert consensus around these everyday scenarios after a thorough literature review. The study not only helps to identify interventions deemed effective and evidence-based but also clears the confusion around several interventions not supported by evidence, or where the evidence was insufficient to justify their routine use.

As previously discussed, the multipronged approach used by contemporary enhanced care pathways augments the effectiveness of these bundles. Conversely, the same multifaceted method makes it impossible to assess the impact of individual bundle elements. Given their proven, indisputable effectiveness, I highly doubt that the enhanced recovery bundles will be subjected to randomized controlled trials in the near future. However, increasing cumulative experience with almost universal adaption of these care bundles will eventually allow us to assign weight to the individual elements via methodical retrospective reviews. Until then, this study will serve as valuable blueprint guiding intraoperative surgeon-initiated interventions.


1. Ruiz-Tovar J, Boermeester MA, Bordeianou L, et al. Delphi consensus on intraoperative technical/surgical aspects to prevent surgical site infection after colorectal surgery. J Am Coll Surg. 2022;234:1–11.
2. Zimlichman E, Henderson D, Tamir O, et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med. 2013;173:2039–2046.
3. World Health Organization [Internet]. Global guidelines for the prevention of surgical site infection, 2nd ed. 2018. Available at:
4. Berríos-Torres SI, Umscheid CA, Bratzler DW, et al.; Healthcare Infection Control Practices Advisory Committee. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg. 2017;152:784–791.
5. Liu Z, Dumville JC, Norman G, et al. Intraoperative interventions for preventing surgical site infection: an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2018;2:CD012653.
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