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Table 2 Gaps in research for the prevention of SSI

From: Highlighting the gaps in quantifying the economic burden of surgical site infections associated with antimicrobial-resistant bacteria

Main topicRecommended
Parenteral antimicrobial prophylaxisSelection of the most appropriate antibiotic according specific to different surgical procedure especially cardiac and vascular surgeries
The optimal timing of preoperative SAP according specific to different surgical procedure [15]
The optimal doses, intra-operative dose adjustments and re-dosing protocols of antibiotics [15]
The effect of weight-adjusted parenteral antimicrobial prophylaxis dosing on the risk of SSI [15]
The effect of prolonged antibiotic prophylaxis on the microbiome
Nonparenteral antimicrobial prophylaxisThe effect of intra-operative antimicrobial irrigation
Comparisons between the most commonly-used irrigation practices
Evaluation of the practices of soaking prosthetic devices in antimicrobial solutions before implantation for the prevention of SSI
Assessment of the need for applying an autologous platelet-rich plasma for the prevention of SSI [15]
Evaluation of the use of Antimicrobial-coated sutures for the prevention of SSI [15]
Comparison between the antimicrobial coated and non-coated sutures using the same type of suture material, including non-absorbable sutures
Evaluation of the use of antimicrobial dressings applied to surgical incisions after primary closure in the operating room for the prevention of SSI [15]
Investigation of potential effects and adverse effects related to the use silver-containing dressings especially in orthopedic and cardiac surgery
Comparison between the uses of opaque dressings and transparent ones in terms of postoperative visual examination and the duration of keeping the primary dressing in place
Glycemic controlThe optimal hemoglobin A1C target levels for the prevention of SSI in patients with and without diabetes [15]
The optimal route of insulin administration and the optimal timing and duration of perioperative glycemic control [15]
The optimal duration of continued postoperative glucose control
Comparison of different blood glucose target levels to define the optimal level with minimum risk of hypoglycemia
NormothermiaComparison and selection of the optimal warming device and the proper timing and duration of warming practices
The optimal timing, duration and limit of normothermia [15] and determine the target temperature
Perioperative oxygenationThe administration of increased FIO2 via endotracheal intubation during only the intra-operative period in patients with normal pulmonary function undergoing general anesthesia [15]
The optimal target level, duration, and delivery method of FIO2 for the prevention of SSI [15]
The administration of increased FIO2 via face mask during the perioperative period in patients with normal pulmonary function undergoing general anesthesia without endotracheal intubation or neuraxial anesthesia [15]
The administration of increased FIO2 via face mask or nasal cannula during only the postoperative period in patients with normal pulmonary function [15]
The optimal target level, duration, and delivery method of Fio2 [15]
Investigations of the benefit of post-extubation hyperoxemia, including different durations, concentrations and oxygen administration routes
The effect of hyperoxygenation on the incidence of SSI
The consequences of the use of a higher concentration of narcotics, hypnotics or inhalational agents or muscle relaxants
Antiseptic prophylaxisThe optimal timing of the preoperative shower or bath, the total number of soap or antiseptic agent applications, or the use of chlorhexidine gluconate washcloths [15]
Cost-effectiveness analyses to examine timing and duration of bathing in different types of surgery and wound classes, especially in LMICs
Comparison of different antiseptic agents to each other and to plain soap for preoperative bathing
Assessment of the effect of soap or antiseptics on the skin microbiome
Evaluation of the effect of chlorhexidine gluconate (CHG) in reducing SSI and their cost implications
The need for a antimicrobial sealant immediately after intraoperative skin preparation [15]
The need of plastic adhesive drapes with or without antimicrobial properties [15]
The practice intraoperative irrigation of deep or subcutaneous tissues with aqueous iodophor solution [15]
The practice of intraperitoneal lavage with aqueous iodophor solution in contaminated or dirty abdominal procedures [15]
The repeat application of antiseptic agents to the patient’s skin immediately before closing the surgical incision [15]
Comparison of specific preparations containing CHG, PVP-I and other antiseptics in alcohol-based and other solutions
Blood transfusionThe effect of blood transfusions on the risk of SSI in prosthetic joint arthroplasty
Perioperative discontinuation of Immunosuppressive agentsThe effect of systemic corticosteroid or other immunosuppressive therapies on the risk of SSI in prosthetic joint arthroplasty [15]
The optimal time between discontinuation of immunosuppressive
The optimal dose of the various immunosuppressive therapy agents including new ones with regards to the SSI rate
The use and timing of preoperative intra-articular corticosteroid injection on the incidence of SSI in prosthetic joint arthroplasty [15]
AnticoagulationThe use of venous thromboembolism prophylaxis on the incidence of SSI in prosthetic joint arthroplasty [15]
Orthopedic surgical space suitThe use of orthopedic space suits or the health care personnel who should wear them for the prevention of SSI in prosthetic joint arthroplasty [15]
BiofilmThe cement modifications and the prevention of biofilm formation or SSI in prosthetic joint arthroplasty [15]
Prosthesis modifications for the prevention of biofilm formation or SSI in prosthetic joint arthroplasty [15]
The uses of vaccines for the prevention of biofilm formation or SSI in prosthetic joint arthroplasty [15]
Decolonization with mupirocin for the prevention of Staphylococcus aureus infection in nasal carriersDetermination of the surgical patient population that should undergo screening for S. aureus carriage
Determination of the timing and duration of mupirocin administration and bathing in surgical patients
Investigating other agents for the decolonization of nasal S. aureus carriers scheduled for surgery
Screening for extended-spectrum beta-lactamase colonization and the impact on surgical antibiotic prophylaxisInvestigations of the tailored modification of SAP in areas with a high prevalence of ESBL-producing Enterobacteriacae, including patients known to be colonized with ESBL, is more effective in reducing the risk of SSI than no modification of the standard prophylaxis
The effect of a routine screening for ESBL prior to surgery on the widespread use of broad-spectrum antibiotics pre-surgery in ESBL-colonized patients and the emergence of resistance in gram negative bacteria, especially carbapenem-resistant Enterobacteriacae
Mechanical bowel preparation and the use of oral antibioticsComparison of oral antibiotics and adequate intravenous prophylactic antibiotics vs. adequate intravenous prophylactic antibiotics only RCT focusing on laparoscopic procedures
Hair removalEvaluation of the optimal timing and the most appropriate setting (ward vs. home) for the hair removal procedure when it is considered necessary by the surgeon
The best and most acceptable methods of hair removal in settings with limited resources need to be investigated, including low-cost solutions
Test evidence-based procedures on how to decontaminate clippers
Studies with a focus on the use of clippers in LMICs
Surgical hand preparationComparison of the effectiveness of various antiseptic products with sustained activity to reduce SSI vs. ABHR or antimicrobial soap with no sustained effect
Assessment of the interaction between products used for surgical hand preparation and the different types of surgical gloves, in relation to SSI outcome
Nutritional supportThe impact of nutritional support in LMICs
Investigating the benefit of other nutritional elements (for example, iron, zinc) and vitamins
The optimal timing and duration of the administration of nutritional support in relation to the time of surgery
Maintenance of adequate circulating volume control/normovolemiaIdentification of the most accurate and least invasive method of measuring normovolemia and assess its influence with regard to tissue oxygenation and normothermia
Drapes and gownsInvestigating the use of sterile disposable compared to sterile reusable drapes and surgical gowns in terms of SSI prevention
Types of materials (including permeable and impermeable materials) and address environmental concerns (water, energy, laundry, waste, etc.)
Investigating whether drapes should be changed during the operation and if this measure has an effect on SSI rates
Investigating the potential benefits of these products
Wound protector devicesComparison of single with double-ring WP devices and reporting adverse events related to the intervention
Prophylactic negative pressure wound therapyInvestigating the use of pNPWT for SSI prevention
The identification the cost effectiveness of pNPWT in different groups of patients including those undergoing contaminated and dirty procedures
The identification the optimal level of negative pressure and duration of application
Use of surgical glovesInvestigating the effectiveness of double-gloving compared to the use of a single pair of gloves would be welcome on SSI
Comparing different types of gloving to address the question of the optimal type of gloves to be usedValuation whether a change of gloves during the operation is more effective in reducing the risk of SSI than no change of gloves are needed, including an assessment of the criteria for changing gloves during the surgical procedure
Changing of surgical instrumentsInvestigating the change of instruments prior to wound closure
Laminar airflow ventilation systems in the context of operating room ventilationThe effects of laminar flow in reducing the SSI rate, require a massive investment with a high sample size to have enough power to see a difference
The impact of fans/cooling devices and natural ventilation on the SSI rate compared to conventional ventilation in order to evaluate whether these systems might be an alternative in resource-limited countries
Optimal timing for wound drain removalThe optimal timing for drain removal especially in orthopedic joint replacement and cardiac surgery and the effect on SSI
Investigating the benefit of early drain removal in pediatric populations and among neonates
  1. LMICs low–middle-income countries, SAP surgical antibiotic prophylaxis, PK pharmacokinetic, PD pharmacodynamics, FIO2 fraction of inspired oxygen, CHG chlorhexidine gluconate (CHG), ESBL extended spectrum beta-lactamase, MBP mechanical bowel production, ABHR alcohol-based hand rub, pNPWT prophylactic negative pressure wound therapy, OR operating room