Buscar en
Cirugía Española (English Edition)
Toda la web
Inicio Cirugía Española (English Edition) Prevention of Surgical Site Infection in Abdominal Surgery. A Critical Review of...
Journal Information
Vol. 92. Issue 4.
Pages 223-231 (April 2014)
Visits
8075
Vol. 92. Issue 4.
Pages 223-231 (April 2014)
Review article
DOI: 10.1016/j.cireng.2013.08.003
Full text access
Prevention of Surgical Site Infection in Abdominal Surgery. A Critical Review of the Evidence
Medidas de prevención de la infección del sitio quirúrgico en cirugía abdominal. Revisión crítica de la evidencia
Visits
...
Jaime Ruiz Tovara,b, Josep M. Badiaa,c,??
Corresponding author
jmbadia@fhag.es

Corresponding author.
a Sección de Infección Quirúrgica, Asociación Española de Cirujanos, Spain
b Servicio de Cirugía, Hospital General Universitario de Elche, Universidad Miguel Hernández, Elche, Alicante, Spain
c Servicio de Cirugía, Hospital General Universitari de Granollers, Universitat Internacional de Catalunya, Barcelona, Spain
Article information
Abstract
Full Text
Bibliography
Download PDF
Statistics
Tables (4)
Table 1. Preoperative Recommended Dose of Prophylactic Antibiotics.
Table 2. Mean Life of Elimination and Recommendations for Redosing in Most Frequently Used Antibiotics in Systemic Prophylaxis.
Table 3. Antibiotics Recommended for Systemic Prophylaxis.
Table 4. Recommendations to Reduce SSI.
Show moreShow less
Abstract

Surgical site infection (SSI) is associated with prolonged hospital stay, increased morbidity, mortality and sanitary costs, and reduced patients’ quality of life. Many hospitals have adopted guidelines of scientifically validated processes for prevention of surgical site and central-line catheter infections and sepsis. Most of these guidelines have resulted in an improvement in postoperative results. A review of the best available evidence on these measures in abdominal surgery is presented. The best measures are: avoidance of hair removal from the surgical field, skin decontamination with alcoholic antiseptic, correct use of antibiotic prophylaxis (administration within 30–60min before incision, use of 1st or 2nd generation cephalosporins, single preoperative dose, dosage adjustments based on body weight and renal function, intraoperative re-dosing if the duration of the procedure exceeds 2 half-lives of the drug or there is excessive blood loss), prevention of hypothermia, control of perioperative glucose levels, avoidance of blood transfusion and restriction of intraoperative liquid infusion.

Keywords:
Surgical site infection
Prevention
Control
Postoperative complications
Prevention
Resumen

La infección del sitio quirúrgico (ISQ) se asocia a prolongación de la estancia hospitalaria, aumento de la morbimortalidad y gasto sanitario. La adherencia a paquetes sistematizados de medidas de prevención consigue disminuir la tasa de infección. Se presenta un análisis crítico de las medidas de profilaxis de la ISQ en cirugía abdominal. Cuentan con mayor grado de evidencia: no eliminación del vello del campo quirúrgico, descontaminación de la piel con soluciones alcohólicas antisépticas, aplicación correcta de la profilaxis antibiótica sistémica (inicio 30–60min antes de la incisión, uso preferente de cefalosporinas de 1.a y 2.a generación en monodosis, ajuste de la dosis con relación al peso y a la función renal, administración de dosis intraoperatoria en hemorragia > 1.500ml o duración > 2 veces la vida media del antibiótico), mantenimiento de la normotermia, control de la glucemia perioperatoria, limitación de las transfusiones sanguíneas y restricción del aporte intravenoso intraoperatorio.

Palabras clave:
Infección de sitio quirúrgico
Prevención
Control
Complicaciones postoperatorias
Prevención
Full Text
Introduction

Surgical site infection (SSI) is one of the most frequent complications in abdominal surgery. It is associated with prolonged hospital stay, a compromised quality of life and an increase in morbimortality and in costs.1,2 The published variability of SSI incidence depends, among other factors, on its definition.3,4 The centers for disease control (CDC) define SSI as the infection which presents in or near the surgical incision, during the first 30 days, or up to one year, if an implant is inserted.5 The SSI appears when the bacterial inoculum exceeds the immune system's ability to control it. Contamination in abdominal surgery originates from the skin or organs that have been targeted during surgery.6,7

The determinant factors for infection are the surgeon, the pathogen and the patient. The surgeon plays a principal role in surgical infection. His or her experience and skill may reduce the inoculum to dimensions which the body's own defences are able to control. Correct surgery involves the careful management of tissues, good haemostasis, no unnecessary prolongation of surgery and minimised extravasation of intraluminal content. The patient-dependent factors include comorbidities, obesity, smoking habits and advanced age. The standard organisms causing infection have not changed over the last few decades, but the numbers of antibiotic-resistant bacteria have risen.3,4,8

Both pharmacological and non-pharmacological measures are available to the surgeon to reduce bacterial contamination at the surgical site and the incidence of SSI. The aim of this review was to update the best evidence available on preventive measures for SSI in abdominal surgery.

Shower Before Surgery

It has been demonstrated that a shower before surgery with chlorhexidine results in greater reduction of bacterial contamination of the skin.9,10 However, several meta-analyses have been unable to correlate this reduction in colonisation with a lower incidence of SSI.11,12 Although a pre-operative shower is recommended, there is little difference when comparing the use of soap and water with that of antiseptic solutions.

Nevertheless, in nasal methicillin-resistant Staphylococcus aureus (MRSA) carriers, nasal decontamination with chlorhexidine or mupirocin ointment combined with a chlorhexidine shower is recommended. This reduces the amount of bacteria and lowers the risk of infection.13,14

Hair Removal

Hair has traditionally been removed from peri-incisional skin in diverse ways (depilation, shaving). The lowest rate of infection is achieved when the hair is not cut. When removal is considered necessary, electric shavers with disposable heads lead to lower rates of infection than manual devices.15 This procedure should be carried out a few hours prior to surgery with care taken not to cut the skin.14

Decontamination of the Skin at the Surgical Site

Alcohol is the most microbiologically active agent for disinfection, but its anti-microbial effect disappears after a few minutes; it is inflammable, and contraindicated on mucose membranes. Its use for surgical preparation has therefore been practically discontinued. Antiseptics such as chlorhexidine gluconate (CG) and povidone iodine (PI) are less active than alcohol, but they have a greater residual effect. Both come in aqueous or alcohol solutions, the latter being more effective than CG and (PI) alone. Despite recent studies,16,17 the debate continues on the most effective antiseptic. Systematic reviews confirm the significant role played by alcohol associated with antiseptics and highlight that the majority of studies compare 2 agents (alcohol and CG) against one (PI),18 and the efficacy of alcoholic chlorhexidine is put down to chlorhexidine alone. Disinfection with alcohol on its own is recommended for taking blood cultures19 and with CG–alcohol for the insertion of venous catheters.20 However, for abdominal surgery the question of whether CG–alcohol is better than PI–alcohol has not been resolved.

Any antiseptic should work for 2–3min and must be left to dry before placing surgical drapes. Alcohol-based antiseptics should be of low concentration and be left to evaporate to reduce the risk of burns when using the electric scalpel.14,17,21

Wound Protectors

Protectors placed around the edges of the surgical wound protect the abdominal wall from drying out, trauma and contamination. Their use has been demonstrated to reduce the wound inoculum at the end of surgery although, depending on the type used, this does not always correlate with a lower incidence of SSI. Wet cotton compresses and buds are permeable to bacteria after a short time. However, one meta-analysis concludes that plastic protectors reduce SSI in abdominal surgery. The effect of the plastic barrier increases with the level of surgical contamination.22

Plastic adhesives on the surgical site are an attempt to minimise wound contamination with cutaneous germs. A Cochrane review found no evidence to show a reduction in SSI with their use; on the contrary, there is some evidence to demonstrate that it increases.23

Skin Incision

Skin incision with an electric scalpel significantly increases the risk of infection; therefore a cold scalpel should be used for dermal incision. When bleeding occurs around the edges, electrocautery should be selectively used on bleeding points.24

Aponeurotic Suture

Monofilaments are less likely to become contaminated than braided ones. Bacteria can adhere better on the latter and the phagocytic capacity of the host cells decreases. Continuous sutures are associated with a lower risk of infection than interrupted ones, possibly due to more homogeneous distribution of pressure on the tissues and the smaller quantity of foreign bodies in the wound.25 Suture materials which are impregnated with antibacterial substances obtain a reduction of bacterial concentration in the wound.26,27 Several studies suggest that sutures impregnated with triclosan reduce incisional and organ-lining SSI,27,28 although independent, more statistically powered analysis is required in order to recommend their routine use.

Delayed Primary Suture of the Wound

Delayed primary suture of the wound is valid for a selected group of highly contaminated surgical interventions.14,29 The wound is left open with compresses impregnated in serum and placed next to the edges when tissue appearance is correct.30 A randomised trial in dirty abdominal wounds showed an SSI rate of 42.5% with primary closure, compared with 2.7% with delayed primary suture.30

Intra-abdominal Drains

In elective surgery, the objective of drains is to eliminate excess fluids from a cavity and control anastomosis. Both aspects have been questioned and there is extensive evidence that casts doubt on their use and demonstrates a negative effect of drains in abdominal surgery (surgery of the colon, cholecystecomy, hepatectomy, gastrectomy) and extra abdominal surgery (thyroid, hernioplasty). Drains should be avoided, but if they are used, they should be closed, one directional, and suction.14,31,32

Topical Prophylaxis

Although inconclusive, there is evidence in favour of irrigating the surgical site with antibiotic solutions combined with systemic prophylaxis, which suggests that there are added benefits.33–35 The majority of these studies are in experimental peritonitis, showing reductions in SSI and mortality of up to 65%.36 However, clinical trials do not confirm these benefits,37 due to differences in the time of development and size of inoculum between clinical and experimental conditions. The effectiveness of prophylactic irrigation of the abdominal cavity with gentamycin and clindamycin in elective colorrectal surgery has been demonstrated, reducing SSI rates.38 Further trials to confirm these results and the most appropriate agent are needed.

Results regarding slow-release topical antibiotics are controversial. Animal models demonstrate SSI reduction with additive effects to systemic antibiotherapy.39 In colorectal surgery, subcutaneous collagen sponges with gentamycin obtain a significant reduction in SSI.40 However, other authors have not been able to reproduce these benefits and have even found that SSI increases, explained by the short half-life of gentamycin and the foreign body effect of the sponge.41

Irrigation of the abdominal cavity with antiseptic solutions such as PI or chlorhexidine has not demonstrated efficacy and is associated with the appearance of adverse effects such as sclerosing mesenteritis.42,43

Mupirocin ointment reduces complications associated with central venous routes in haemodialysis patients who are non-carriers of MRSA and could be valid in prophylaxis of abdominal surgery infection, but this hypothesis is yet to be confirmed.44

In colorectal surgery, carboxymethyl cellulose dressings which contain silver may have an effect on superficial incisional SSI,45 but not on deep incisional or organ space SSI.

Mechanical Bowel Preparation in Colorectal Surgery

Mechanical bowel preparation (MBP) with evacuating solutions is used with the intention to reduce complications of infection and post-operative anastomotic dehiscence.46 Current evidence suggests that MBP does not reduce the rate of complications, including anastomotic failure.47–50 Several authors refer to an increase in complications associated with MBP, such as hydroelectrolytic conditions, convulsions or spontaneous oesophageal rupture.51 Due to this evidence, many colorectal surgeons have stopped using MBP52 and, unfortunately, administrating oral antibiotic prophylaxis as well.

Oral Antibiotic Prophylaxis in Colorectal Surgery

Several meta-analyses have demonstrated that the combination of intravenous and oral antibiotic prophylaxis reduces up to 26% of SSI risk when compared with isolated intravenous prophylaxis.53,54 This practice may be of little use in the absence of MBP due to the high bacterial inoculum in a faeces-filled colon. However, no publications describe the effect of oral antibiotics in the absence of MBP. The most frequently administered oral antibiotics are: neomycin with erythromycin or metronidazole or kanamycin with erithomycin or metronidazole.55

Systemic Antibiotic Prophylaxis

Antibiotic prophylaxis should achieve antibiotic levels in the tissues above the minimum inhibitory concentration of germs before they contaminate the surgical site. They should therefore be administered 30min prior to commencement of surgery.56 In general, prophylaxis is not indicated in clean surgery, as risk of SSI is lower than 2%.14,56 However, the latest meta-analyses on prophylaxis in herniorrhaphy demonstrate the antibiotic's protective effect, particularly in hernioplasty.57,58 Antibiotic prophylaxis is also recommended59 in breast surgery. In colorectal surgery, the combined administration of antibiotics compared with aerobic and anaerobic pathogens reduces this by 59%.14

Obesity and renal failure require an adjustment of the prophylactic antibiotic dosage. Alexander et al.14 established an 80kg cut-off point to adjust the dosage (Table 1). The majority of antibiotics are eliminated via the kidney, and the dosage must therefore be adjusted in renal failure, depending on creatinine clearance.60

Table 1.

Preoperative Recommended Dose of Prophylactic Antibiotics.

  <80kg  81–160kg  >160kg 
Cefazolin  233
Cefuroxime  1.533
Clindamycin  600mg  900mg  1200mg 
Gentamicin  4.5–5mg/kg  4.5–5mg/kg (maximum 420mg)  540mg 
Metronidazole  500mg  1000mg  1500mg 
Source: Taken from Bibbo et al.16

A single prophylactic antibiotic dose is as effective as multiple doses.61,62 Prolonged use of antibiotics provides no benefits and actually increases the risk of developing resistance.63 Intraoperative redosing is more important than prolongation of prophylaxis after surgery. Indications for redosing are blood loss over 1500ml and prolongation of the operation over twice the half-life of the antibiotic14,55 (Table 2). When creatinine clearance is below 50ml/min, the redosing interval should be twice that established for a patient with normal renal function, but when it is under 20ml/min, the time interval should be quadrupled.14

Table 2.

Mean Life of Elimination and Recommendations for Redosing in Most Frequently Used Antibiotics in Systemic Prophylaxis.

  Mean life of elimination (h)  Intraoperative redosing interval (h) 
Cefazolin  1.5 
Cefuroxime  1.5 
Clindamycin  2.5 
Gentamicin  1.5 
Metronidazole 

It is important to evaluate the local patterns of bacterial sensitivity when selecting the appropriate antibiotic. We know the cut-off points of minimal inhibitory concentration (MIC) from which a bacteria is considered resistant, but there is no consensus on the cut-off percentage of resistant strains from which we consider an antibiotic ineffective for prophylaxis.55 The antibiotics used in prophylaxis have to be different from those used in treatment (Table 3). 1st and 2nd generation cephalosporins are thus regarded as ideal drugs.14,64,65 Broad spectrum drugs in high risk surgery prophylaxis have been proposed. Itani et al.4 analysed ertapenem in colorectal surgery, demonstrating a lower incidence of SSI compared with cefotetan. This recommendation has been disputed, arguing that the use of broad spectrum drugs may increase resistance and colonisation by Clostridium difficile.66 Despite this, several clinical guidelines include it as an alternative in elective colorectal surgery.14,67

Table 3.

Antibiotics Recommended for Systemic Prophylaxis.

Type of intervention  Antibiotics of choice  Allergic to betalactams 
General surgery/clean surgery  Cefazolin or cefuroxime  Clindamycin+an aminoglycoside 
Gastroesophageal and hepatobiliopancreatic surgery  Cefazolin or cefuroxime or amoxycillin clavulanate  Clindamycin+an aminoglycoside 
Colorectal surgery  Cefazolin/cefuroxime+metronidazole or metronidazole+an aminoglycoside or amoxycillin clavulanate  Metronidazole+an aminoglycoside 

The most recommended antibiotics in gastroesophageal and hepatobiliary surgery are 1st and 2nd generation cephalosporins and amoxycillin clavulanate. In some Spanish regions prophylaxis with amoxycillin clavulanate is not recommended, due to non urological high resistance rates of Escherichia coli which may reach 25%.68 The 3rd and 4th generation cephalosporins are also effective, but not recommended due to their cost and their relationship with the appearance of MRSA and ESBL enterobacteria. In patients who are allergic to beta-lactams, the combination of vancomycin or clindamycin with an aminoglycoside may be used.14,55,64

Combinations of metronidazole with 1st and 2nd generation cephalosporins are recommended in colorectal surgery (cephuroxim/cefotetan) or with gentamycin. Amoxycillin clavulanate can be used depending on the local resistance pattern. In allergic patients, clindamycin is not recommended due to the rate of resistant Bacteroides fragilis and metronidazole must be opted for. The use of aminoglycosides may be controversial, although they are very effective agents compared with gram-negative bacilli and particularly with Pseudomonas aeruginosa.69 Due to the short half-life of gentamycin (1.5h), single doses of 4.5–5mg/kg are recommended, with a very low toxicity risk. Another disadvantage is its antimicrobial spectrum, since the combination of metronidazole with an aminoglycoside does not cover gram positive microrganisms. This may explain why Streptococcus spp.36 presents in 27% of SSI after elective colorectal surgery.

Body Temperature

Moderate hypothermia (34–36°C) is associated with diverse adverse effects, such as coagulopathies, which result in greater blood loss and which may increase the need for blood transfusion.70 Hypothermia is also associated with prolonged anaesthetic recovery,71 increased hospital stay72 and SSI.73 In colorectal surgery hypothermia was confirmed to triple the risk of wound infection74 and in clean surgery to multiply it by 6.75 The most accepted explanation is the constriction of blood vessels, which reduces blood flow to subcutaneous cellular tissue and oxygen tension.72,73,76 Hypothermia affects cellular and humoral immunity, and its cytokine-mediated regulation.77 Some studies maintain that hyperthermia up to 40°C may be more beneficial, based on the mechanism of fever as an enhancer of the body's defence mechanisms.7,78 However, further studies are needed to confirm these results. The mechanisms for maintaining body temperature must be systemic and local, and include the administration of warming IV fluids, heat lamps and thermal blankets.14,79

Oxygen Therapy

There has been speculation regarding supranormal oxygen delivery increasing partial oxygen pressure in the surgical wound, and thereby increasing the oxidative destruction of bacteria by neutrophils. Studies have been designed comparing the perioperative administration of an 80% FiO2 compared with a 30% FiO2. Although no adverse effects with 80% FiO2 have been described, results are contradictory, with studies which show lower incidences of SSI with hyperoxia80,81 and others which show no significant differences.82,83

Control of Postoperative Glycaemia

Diabetics suffer from a greater incidence of postoperative complications and mortality, including delay in SSI healing.84 In hyperglycaemic situations, there is an increase in catecholamine, cortico-steroid and growth hormone levels, inhibiting the release of oxygen to the wound.85 In studies on hyperglycaemia and SSI in heart surgery with sternotomy, maintaining glycaemic levels between 120 and 160mg/dl for the first 2–3 days after surgery reduces the risk of SSI.86,87 A retrospective study on general and vascular surgery establishes that each increase of 40mg/dl in glycaemia above 110mg/dl represents a 30% increase in the risk of SSI.88 Monitoring of postoperative glycaemia in diabetics is recommended, maintaining levels below 180mg/dl.14

Perioperative Blood Transfusions

Perioperative blood transfusions are an independent predictive factor of SSI,14,89 with a link between the amount of blood transfused and the risk of infection. In surgery for gastrointestinal tumours, transfusion of over 1000ml of red blood cell concentrate is associated with a 6.5 times higher risk of SSI.90 Multivariate analyses with animals, confirm that blood component transfusions are a separate risk factor for the development of SSI.91

A recent review of perioperative care strategy confirms that the need for a blood transfusion is associated with a higher incidence of SSI, which results in poorer postoperative recovery.92 However, according to Hranjec et al., reducing leucocytes in transfused elements may be beneficial.93

Infusion of Intraoperative IV Liquids

Intraoperative hyperhydration leads to oedemas which hinder correct healing, and this leads to an increase in SSI. A multi-centre trial demonstrates that the restriction of intraoperative fluids is associated with a lower incidence of SSI.94 Furthermore, liquid restriction is associated with lower postoperative morbimortality, due to an improvement in respiratory function, postoperative ileus and the risk of deep vein thrombosis.95

Multimodal rehabilitation programmes in colorectal surgery include the administration of glycoside solutions up to 3h before surgery, aimed at reducing the catabolic response induced by surgical aggression. The ingestion of fluids ending with 400ml of glucose solution would help to prevent postoperative dehydration.95

Nutritional Status

Preoperative malnutrition is associated with changes in body composition and the dysfunction of cardiopulmonary, renal and digestive systems. Immunosuppression associated with malnutrition facilitates SSI and intraabdominal sepsis. The term immunonutrition refers to the potential usefulness of certain immuno-nutrients in clinical development. The 3 most important immunonutrients are omega 3 fatty acids, glutamine and arginine. Several studies have attempted to demonstrate that the perioperative ingestion of immunonutrients is associated with a lower incidence of infections. A meta-analysis by Cerantola et al.96 shows a decrease in complications, particularly postoperative infections, and a reduction in hospital stay. However, no significant differences arise in postoperative mortality. In 2012, a meta-analysis on digestive cancer showed that perioperative immunonutrition is effective, safe, and reduces hospital stay and postoperative infections and complications.97 However, Klek et al.98 found no significant differences in the rate of complications, postoperative infection, mortality and hospital stay in a randomised clinical trial. In light of the discrepancies between these results and the high price of formulas, there is a need for independent studies to be conducted before including or eliminating immunonutrition from the general recommendations on SSI reduction.

Checklist

In the last few years several checklists have been designed to ensure that correct perioperative parameters are applied. These facilitate the interrelation between members of the surgical team and an improvement in overall patient care. Haynes et al. carried out a prospective study of the fulfilment of the WHO checklist. They confirmed that perioperative mortality was lowered from 1.5% to 0.8% and the rate of complications fell from 11% to 7%.99

Bundles

The use of bundles or systemised packages for the prevention of postoperative complications has become popular during the last decade. These are either applied generally or in high risk situations such as colorectal surgery. In 2004, the CDC initiated the Surgical Infection Prevention Project (SIP) to ensure that a few basic evidence-based measures for the prevention of SSI are implemented (appropriate use of prophylactic antibiotics, administration during the hour prior to incision and removal before 24h, good protocol for body hair management and maintenance of normothermia). When these measure were applied, in 2007 Hedrick et al. reported higher compliance with the prophylaxis protocol and a reduction in SSI from 25.6% to 15.9% in colon surgery compared with a previous series.100 However, a similar study found no differences in SSI rate (19%) despite detecting an improvement in the process.101 In 2011, a randomised study of 211 colorectal operations compared its “traditional” bundle with another bundle which, among other modifications, had removed mechanical preparation of the colon and oral antibiotics. Despite managing to improve compliance with evidence-based measures, an increase in SSI from 24% to 45% was detected.102 In Spain, a multicentre observational study of SSI incidence in colorectal surgery with the application of a bundle similar to that of the SIP Project presented 23.2% of SSI in 611 colorectal interventions.103

To conclude, the adoption of a package of measures for the prevention of SSI with good scientific evidence (Table 4), its protocolisation and monitoring that it is adhered to lead to an improvement in the surgical process. Adherence to these bundles by preparing a checklist also helps to reduce the rate of SSI. However, in the struggle to reduce postoperative infection there remain several fairly unknown and poorly systematised factors, and therefore an impeccable individual surgical technique combined with good criteria in choosing the most appropriate prophylaxis measures is still irreplaceable.

Table 4.

Recommendations to Reduce SSI.

1. Administer a preoperative shower with soap and water 
2. If intranasal MRSA is detected: nasal decontamination with mupirocin+administer preoperative shower with chlorhexidine soap 
3. Do not eliminate hair during surgery or eliminate hair with an electric shaver with a disposable head 
4. Decontaminate the skin during surgery with a chlorhexidine alcohol solution or povidone. Do not dry. Leave the solution to take effect for 2–3min 
5. Make skin incision with a cold scalpel. Do not overuse electrocoagulation 
6. Perform fascial closure with monofilament sutures 
7. Use primary deferred suture of the wound in dirty surgery 
8. Avoid intra-abdominal drains. If they are used: closure is to be one directional and aspirative 
9. In colorectal surgery do not administer mechanical preparation of the colon. Administer a combination of oral and systemic antibiotics 
10. Systemic antibiotic prophylaxis:Commence 30–60min before incisionFlat dose, adjusted to the ideal weight and kidney functionRedosing if blood loss>1500ml or if surgery prolonged>twice the mean age of the antibioticPreoperative monodose. Do not prolong the prophylaxis with postoperative dose1st and 2nd generation cephalosporins usage preferred 
11. Avoid hypothermia 
12. Maintain postoperative glycaemia below 180mg/dl in diabetics 
13. Avoid perioperative blood transfusions 
14. Restrict IV introperative liquids 
Conflict of Interest

The authors have no conflict of interest to declare related to this review.

References
[1]
T. Anthony, J. Long, L.S. Hynan, G.A. Sarosi Jr., F. Nwariaku, J. Huth, et al.
Surgical complications exert a lasting effect on disease-specific health-related quality of life for patients with colorectal cancer.
Surgery, 134 (2003), pp. 119-125
[2]
J.B. Dimick, S.L. Chen, P.A. Taheri, W.G. Henderson, S.F. Khuri, D.A. Campbell Jr..
Hospital costs associated with surgical complications: a report from the private sector National Surgery Quality Improvement Program.
J Am Coll Surg, 199 (2004), pp. 531-537
[3]
R. Tang, H.H. Chen, Y.L. Wang, C.R. Changchien, J.S. Chen, K.C. Hsu, et al.
Risk factors for surgical site infection after elective resection of the colon and rectum: a single-center prospective study of 2809 consecutive patients.
Ann Surg, 234 (2001), pp. 181-189
[4]
K.M. Itani, S.E. Wilson, S.S. Awad, E.H. Jensen, T.S. Finn, M.A. Abramson.
Ertapenem versus cefotetan prophylaxis in elective colorectal surgery.
N Engl J Med, 355 (2006), pp. 2640-2651
[5]
T.C. Horan, M. Andrus, M.A. Dudeck.
CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting.
Am J Infect Control, 36 (2008), pp. 309-332
[6]
J. Blumetti, M. Luu, G. Sarosi, K. Hartless, J. McFarlin, B. Parker, et al.
Surgical site infections after colorectal surgery: do risk factors vary depending on the type of infection considered?.
Surgery, 142 (2007), pp. 704-711
[7]
B.W. Murray, S. Huerta, S. Dineen, T. Anthony.
Surgical site infection in colorectal surgery: a review of nonpharmacologic tools of prevention.
J AM Coll Surg, 211 (2010), pp. 812-822
[8]
E. Nve Obiang, J.M. Badia Pérez.
Infección del sitio quirúrgico: Definición, clasificación, factores de riesgo.
Guías Clinicas de la Asociación Española de Cirujanos. Infecciones quirúrgicas, pp. 99-120
[9]
R.A. Garibaldi, D. Skolnick, T. Lerer, A. Poirot, J. Graham, E. Krisuinas, et al.
The impact of preoperative skin disinfection on preventing intraoperative wound contamination.
Infect Control Hosp Epidemiol, 9 (1988), pp. 109-113
[10]
D.A. Leigh, J.L. Stronge, J. Marriner, J. Sedgwick.
Total body bathing with «Hibiscrub» (chlorhexidine) in surgical patients: a controlled trial.
J Hosp Infect, 4 (1983), pp. 229-235
[11]
A.H. Stewart, P.S. Eyers, J.J. Earnshaw.
Prevention of infection in peripheral arterial reconstruction: a systematic review and meta-analysis.
J Vasc Surg, 46 (2007), pp. 148-155
[12]
J. Webster, W. Osborne.
Preoperative bathing or showering with skin antiseptics to prevent surgical site infection.
Cochrane Database Syst Rev, 18 (2007), pp. CD004985
[13]
H.F.L. Wertheim, D.C. Melles, M.C. Vos, W. van Leeuwen, A. van Belkum, H.A. Verbrugh, et al.
The role of nasal carriage in Staphylococcus aureus infections.
Lancet Infect Dis, 12 (2005), pp. 751-762
[14]
J. Wesley Alexander, J.S. Solomkin, M.J. Edwards.
Updated recommendations for control of surgical site infections.
Ann Surg, 253 (2011), pp. 1082-1093
[15]
J. Tanner, D. Woodings, K. Moncaster.
Preoperative hair removal to reduce surgical site infection.
Cochrane Database Syst Rev, 19 (2006), pp. CD004122
[16]
C. Bibbo, D.V. Patel, R.M. Gehrmann, S.S. Lin.
Clorhexidine provides superior skin decontamination in foot and ankle surgery: a prospective randomized study.
Clin Orthop Relat Res, 438 (2005), pp. 204-208
[17]
R.O. Darouiche, M.J. Wall Jr., K.M. Itani, M.F. Otterson, A.L. Webb, M.M. Carrick, et al.
Clorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis.
N Engl J Med, 362 (2010), pp. 18-26
[18]
M. Maiwald, E.S. Chan.
The forgotten role of alcohol: a systematic review and meta-analysis of the clinical efficacy and perceived role of chlorhexidine in skin antisepsis.
[19]
D. Caldeira, C. David, C. Sampaio.
Skin antiseptics in venous puncture-site disinfection for prevention of blood culture contamination: systematic review with meta-analysis.
J Hosp Infect, 77 (2011), pp. 223-232
[20]
Rickard C, Ray-Barruel G. Systematic review of infection control literature relating to intravascular devices. In: National Health and Medical Research Council (NHMRC). Australian guidelines for the prevention and control of infection in healthcare. Appendix 2: Process Report. Canberra: Commonwealth of Australia. Available from: http://www.nhmrc.gov.au/guidelines/publications/cd33.
[21]
B.R. Swenson, T.L. Hedrick, R. Metzger, H. Bonatti, T.L. Pruett, R.G. Sawyer.
Effects of preoperative skin preparation on postoperative wound infection rates: a prospective study of 3 skin preparation protocols.
Infect Control Hosp Epidemiol, 30 (2009), pp. 964-971
[22]
A. Gheorghe, M. Calvert, T.D. Pinkney, B.R. Fletcher, D.C. Bartlett, W.J. Hawkins, et al.
Systematic review of the clinical effectiveness of wound-edge protection devices in reducing surgical site infection in patients undergoing open abdominal surgery.
Ann Surg, 255 (2012), pp. 1017-1029
[23]
J. Webster, A. Alghamdi.
Use of plastic adhesive drapes during surgery for preventing surgical site infection.
Cochrane Database Syst Rev, 4 (2007), pp. CD006353
[24]
G.W. Ji, Y.-Z. Wu, X. Wang, H.X. Pan, P. Li, W.Y. Du, et al.
Experimental and clinical study of influence of high-frequency electric surgical knives on healing ob abdominal incision.
World J Gastroenterol, 12 (2006), pp. 4082-4085
[25]
A.J. Derzie, F. Silvestri, E. Liriano, P. Benotti.
Wound closure technique and acute wound complications in gastric surgery for morbid obesity: a prospective randomized trial.
J Am Coll Surg, 191 (2000), pp. 238-243
[26]
P. Gilbert, A.J. McBain.
Literature-based evaluation of the potential risks associated with impregnation of medical devices and implants with triclosan.
Surg Infect, 3 (2002), pp. S55-S63
[27]
X. Ming, S. Rothenburger, M.M. Nichols.
In vivo antibacterial efficacy of PDS plus (polidioxanone with triclosan) suture.
Surg Infect, 9 (2008), pp. 451-457
[28]
I. Galal, K. El-Hindawi.
Impact of using triclosan-antibacterial sutures on incidence of surgical site infection.
Am J Surg, 202 (2011), pp. 103-108
[29]
I. Fogdestam, F.T. Jensen, S.K. Nilsson.
Delayed primary closure. Blood-flow in healing rat skin incisions.
Scand J Plast Reconstr Surg, 15 (1981), pp. 81-85
[30]
D.D. Duttaroy, J. Jitendra, B. Duttaroy, U. Bansal, P. Dhameja, G. Patel, et al.
Management strategy for dirty abdominal incisions: primary or delayed primary closure? A randomized trial.
Surg Infect, 10 (2009), pp. 129-136
[31]
E.C. Jesus, A. Karliczek, D. Matos, A.A. Castro, A.N. Atallah.
Prophylactic anastomotic drainage for colorectal surgery.
Cochrane Database Syst Rev, 18 (2004), pp. CD002100
[32]
J. Ruiz-Tovar, I. Ortega, J. Santos, L. Sosa, L. Armañanzas, M. Diez Tabernilla, et al.
¿Existe alguna indicación de colocación de drenaje en la colecistectomía laparoscópica electiva?.
[33]
N.A. Halasz.
Wound infection and topical antibiotics: the surgeon's dilemma.
Arch Surg, 112 (1977), pp. 1240-1244
[34]
K.S. Scher, J.B. Peoples.
Combined use of topical and systemic antibiotics.
Am J Surg, 161 (1991), pp. 422-425
[35]
D.L. Cavanaugh, J. Berry, S.R. Yarboro, L.E. Dahners.
Better prophylaxis against surgical site infection with local as well as systemic antibiotics. An in vivo study.
J Bone Joint Surg Am, 91 (2009), pp. 1907-1912
[36]
S.H. Silverman, N.S. Ambrose, D.J. Youngs, A.F. Shepherd, A.P. Roberts, M.R. Keighley.
The effect of peritoneal lavage with tetracycline solution on postoperative infection. A prospective, randomized, clinical trial.
Dis Colon Rectum, 29 (1986), pp. 165-169
[37]
C. Platell, J.M. Papadimitriou, J.C. Hall.
The influence of lavage on peritonitis.
J Am Coll Surg, 191 (2000), pp. 672-680
[38]
J. Ruiz-Tovar, J. Santos, A. Arroyo, C. Llavero, L. Armañanzas, A. López-Delgado, et al.
Effect of peritoneal lavage with clindamycin–gentamicin solution on infections after elective colorectal cancer surgery.
J Am Coll Surg, 214 (2012), pp. 202-207
[39]
S. Galandiuk, W.R. Wrightson, S. Young, S. Myers, H.C. Polk Jr..
Absorbable, delayed-released antibiotic beads reduce surgical wound infection.
Am Surg, 63 (1997), pp. 831-835
[40]
H.J. Rutten, P.H. Nijhuis.
Prevention of wound infection in elective colorectal surgery by local application of a gentamicin-containing collagen sponge.
Eur J Surg Suppl, 578 (1997), pp. 31-35
[41]
E. Bennett-Guerrero, T.N. Pappas, W.A. Koltun, J.W. Fleshman, M. Lin, J. Garg, et al.
Gentamicin-collagen sponge for infection prophylaxis in colorectal surgery.
N Eng J Med, 363 (2010), pp. 1038-1049
[42]
P.R. Bicalho, C.A. Mayrink, F. Fernandes, D.G. Alvarenga, I.D. Araujo, T.A. Nunes, et al.
Treatment with chlorhexidine modifies the healing of colon anastomosis in rats.
J Invest Surg, 24 (2011), pp. 8-12
[43]
J.O. Sieck, R. Cowgill, W. Larkworthy.
Peritoneal encapsulation and abdominal cocoon. Case reports and a review of the literature.
Gastroenterology, 84 (1983), pp. 1597-1601
[44]
M. McCann, Z.E. Moore.
Interventions for preventing infectious complications in haemodialysis patients with central venous catheters.
Cochrane Database Syst Rev, 20 (2010), pp. CD006894
[45]
C.H. Siah, J. Yatim.
Efficacy of a total occlusive ionic silver-containing dressing combination in decreasing risk of surgical site infection: an RCT.
J Wound Care, 20 (2011), pp. 561-568
[46]
R.S. Chung, N.J. Gurll, E.M. Berglund.
A controlled trial of whole gut lavage as method of bowel preparation for colonic operations.
Am J Surg, 137 (1979), pp. 75-81
[47]
O. Zmora, A. Mahajna, B. Bar-Zakai, D. Rosin, D. Hershko, M. Shabtai, et al.
Colon and Rectal surgery without mechanical bowel preparation: a randomized prospective trial.
[48]
K. Slim, E. Vicaut, Y. Panis, J. Chipponi.
Meta-analysis of randomized clínical trials of colorrectal surgery with or without mechanical bowel preparation.
Br J Surg, 91 (2004), pp. 1125-1130
[49]
P. Wille-Jorgensen, K.F. Guenaga, D. Matos, A.A. Castro.
Preoperative mechanical bowel cleansing or not? An update meta-analysis.
Colorectal Dis, 7 (2005), pp. 304-310
[50]
C.M. Contant, W.C. Hop, H.P. van’t Sant, H.J. Oostvogel, H.J. Smeets, L.P. Stassen, et al.
Mechanical bowel preparation for elective colorectal surgery: a multicenter randomized trial.
Lancet, 370 (2007), pp. 2112-2117
[51]
Preoperative bowel preparation for patients undergoing elective colorectal surgery: a clinical practice guideline endorsed by the Canadian Society of Colon and Rectal, Surgeons.
Can J Surg, 53 (2010), pp. 385-395
[52]
J.V. Roig, A. García-Fadrique, J. García-Armengol, M. Bruna, C. Redondo, M.J. García-Coret, et al.
Mechanical bowel preparation and antibiotic prophylaxis in colorectal surgery: use by and opinions of Spanish surgeons.
Colorectal Dis, 11 (2009), pp. 44-48
[53]
R.T. Lewis.
Oral versus systemic antibiotic prophylaxis in elective colon surgery: a randomized study and meta-analysis send a message from the 1990s.
Can J Surg, 45 (2002), pp. 173-180
[54]
R.L. Nelson, A.M. Glenny, F. Song.
Antimicrobial prophylaxis for colorectal surgery.
Cochrane Database Syst Rev, 21 (2009), pp. CD001181
[55]
X. Guirao Garriga, J.M. Badia Pérez.
Profilaxis antibiótica en cirugía.
Guías Clínicas de la Asociación Española de Cirujanos. Infecciones quirúrgicas, pp. 121-144
[56]
Informe EPINE 2010. Estudio de prevalencia de las infecciones nosocomiales. Sociedad Española de Medicina Preventiva, Salud Pública e Higiene; 2010. Available from: http://www.sempsph.com/sempsph/attachments/327_Informe%20EPINE-2010%20ESPA%C3%91A.pdf.
[57]
Y. Yin, T. Song, B. Liao, Q. Luo, Z. Zhou.
Antibiotic prophylaxis in patients undergoing open mesh repair of inguinal hernia: a meta-analysis.
Am Surg, 78 (2012), pp. 359-365
[58]
P.P. Goodney, C.M. Birkmeyer, J.D. Birkmeyer.
Short-term outcomes of laparoscopic and open ventral hernia repair: a meta-analysis.
Arch Surg, 137 (2002), pp. 1161-1165
[59]
M. Cunningham, F. Bunn, K. Handscomb.
Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery.
Cochrane Database Syst Rev, 19 (2006), pp. CD005360
[60]
G.F. Strippoli, A. Tong, D. Johnson, F.P. Schena, J.C. Craig.
Antimicrobial agents to prevent peritonitis in peritoneal dialysis: a systematic review of randomized controlled trials.
Am J Kidney Dis, 44 (2004), pp. 591-603
[61]
J.M. Ventura Cerdá, J. Nomdedeu Guinot, M. Alós Almiñana, V.A. Yepes, I. Pérez Salinas, J.L. Salvador Sanchís.
Single preoperative dose of metronidazole plus gentamicin for antimicrobial prophylaxis in colorectal surgery.
Med Clin, 129 (2007), pp. 121-126
[62]
M. McDonald, E. Grabsch, C. Marshall, A. Forbes.
Single versus multiple-dose antimicrobial prophylaxis for major surgery: a systematic review.
Austr N Z J Surg, 68 (1998), pp. 388-395
[63]
S. Harbarth, M.H. Samore, D. Lichtenberg, Y. Carmeli.
Prolonged antibiotic prophylaxis after cardiovascular surgery and its effect on surgical site infections and antimicrobial resistance.
Circulation, 101 (2000), pp. 2916-2921
[64]
Antimicrobial prophylaxis in surgery.
Treat Guidel Med Lett, 7 (2009), pp. 47-52
[65]
D.N. Gilbert, R.C. Moellering, M.A. Sande.
The Sanford guide to antimicrobial therapy.
33rd ed., Antimicrobial Therapy Inc., (2003), pp. 123-124
[66]
D.J. Sexton.
Carbapenems for surgical prophylaxis?.
N Eng J Med, 355 (2006), pp. 2694
[67]
F. Lalla.
Antimicrobial prophylaxis in colorectal surgery: focus on ertapenem.
Ther Clin Risk Manage, (2009), pp. 829-839
[68]
R. Canton, E. Loza, J. Aznar, J. Calvo, E. Cercenado, R. Cisterna, et al.
Antimicrobial susceptibility of gram-negative organisms from intraabdominal infections and evolution of isolates with extended spectrum-lactamases in the SMART study in Spain (2002–2010).
Rev Esp Quimioter, 24 (2011), pp. 223-232
[69]
M. del Mar Casal, M. Causse, F. Rodríguez-López, M. Casal.
Resistencia antimicrobiana en aislados clínicos de Pseudomonas aeruginosa.
Rev Esp Quimioter, 25 (2012), pp. 37-41
[70]
H. Schmied, A.N. Kurz, D.I. Sessler, S. Kozek, A. Reiter.
Mild hypothermia increases blood loss and transfusion requirements during total hip arthroasty.
Lancet, 347 (1996), pp. 289-292
[71]
R. Lenhardt, E. Marker, V. Goll, H. Schernich, A. Kurz, D.I. Sessler, et al.
Mild intraoperative hypothermia prolongs postanesthetic recovery.
Anesthesiology, 87 (1997), pp. 1318-1323
[72]
D.I. Sessler, O. Acka.
Nonpharmacological prevention of surgical wound infections.
Clin Infect Dis, 35 (2002), pp. 1397-1404
[73]
A. Kurtz.
Thermal care in the perioperative period.
Best Pract Res Clin Anesthesiol, 22 (2008), pp. 39-62
[74]
L. Reynolds, J. Beckmann, A. Kurz.
Perioperative complications of hypothermia.
Best Pract Res Clin Anaesthesiol, 22 (2008), pp. 645-657
[75]
A.C. Melling, B. Ali, E.M. Scott, D.J. Leaper.
Effects of preoperative warming on the incidence of wound infection after clean surgery: a randomized controlled trial.
[76]
S. Kumar, P.F. Wong, A.C. Melling, D.J. Leaper.
Effects of perioperative hypothermia and warming in surgical practice.
Int Wound J, 2 (2005), pp. 193-204
[77]
M. Qadan, S.A. Gardner, D.S. Vitale, D. Lominadze, I.G. Joshua, H.C. Polk Jr..
Hypothermia and surgery. Immunologic mechanisms for current practice.
Ann Surg, 250 (2009), pp. 134-140
[78]
A. Jiang, A.S. Cross, I.S. Singh.
Febrile core temperature is essential for optimal host defense in bacterial peritonitis.
Infect Immun, 68 (2000), pp. 1265-1270
[79]
D. Leaper.
Effects of local and systemic warming on postoperative infections.
Surg Infect, 7 (2006), pp. S101-S103
[80]
F.J. Belda, L. Aguilera, J. Garcia de la Asuncion, J. Alberti, R. Vicente, L. Ferrándiz, et al.
Supplemental perioperative oxygen and the risk of surgical wound infection. A randomized controlled trial.
J Am Med Assoc, 294 (2005), pp. 2035-2042
[81]
P.S. Myles, K. Leslie, T.V. Chan, A. Forbes, M.J. Paech, P. Peyton, et al.
Avoidance of nitrous oxide for patients undergoing major surgery. A randomized controlled trial.
Anesthesiology, 107 (2007), pp. 221-231
[82]
K.O. Pryor, T.J. Fahey 3rd, C.A. Lien, P.A. Goldstein.
Surgical site infection and the routine use of perioperative hyperoxia in a general surgical population. A randomized controlled trial.
J Am Med Assoc, 291 (2004), pp. 79-87
[83]
O. Mayzler, N. Weksler, S. Domchik, M. Klein, S. Mizrahi, G.M. Gurman.
Does supplemental perioperative oxygen administration reduce the incidence of wound infection in elective colorectal surgery?.
Minerva Anestesiol, 71 (2005), pp. 21-25
[84]
A.P. Furnary, Y. Wu, S.O. Bookin.
Effect of hyperglycemia and continuous intravenous insulin infusions on outcomes of cardiac surgical procedures: the Portland Diabetic Project.
Endocr Pract, 10 (2004), pp. 21-33
[85]
M. Turina, D.E. Fry, H.C. Polk Jr..
Acute hyperglycemia and the innate immune system: clinical, cellular, and molecular aspects.
Crit Care Med, 33 (2005), pp. 1624-1633
[86]
R. Kramer, R. Groom, D. Weldner, P. Gallant, B. Heyl, R. Knapp, et al.
Glycemic control and reduction of deep sterna wound infection rates: a multidisciplinary approach.
Arch Surg, 143 (2008), pp. 451-456
[87]
C.L. Swenne, C. Lindholm, J. Borowiec, A.E. Schnell, M. Carlsson.
Peri-operative glucose control and development of surgical wound infections inpatients undergoing coronary artery bypass graft.
J Hosp Infect, 61 (2005), pp. 201-212
[88]
M. Ramos, Z. Khalpey, S. Lipsitz, J. Steinberg, M.T. Panizales, M. Zinner, et al.
Relationship of perioperative hyperglycemia and postoperative infections in patients who undergo general and vascular surgery.
Ann Surg, 248 (2008), pp. 585-591
[89]
A. Vignali, M. Braga, P. Dionigi, G. Radaelli, O. Gentilini, A. Bellini, et al.
Impact of a programme of autologous blood donation on the incidence of infection in patients with colorectal cancer.
Eur J Surg, 161 (1995), pp. 487-492
[90]
D.J. Triulzi, N. Blumberg, J.M. Heal.
Association of transfusion with postoperative bacterial infection.
Crit Rev Clin Lab Sci, 28 (1990), pp. 95-107
[91]
S. Galandiuk, C.D. George, J.D. Pietsch, D.C. Byck, R.C. DeWeese, H.C. Polk Jr..
An experimental assessment of the effect of blood transfusion on susceptibility to bacterial infection.
Surgery, 108 (1990), pp. 567-571
[92]
M. Adamina, O. Gie, N. Demartines, F. Ris.
Contemporary perioperative care strategies.
Br J Surg, 100 (2013), pp. 38-54
[93]
T. Hranjec, B.R. Swenson, R.G. Sawyer.
Surgical site infection prevention: how we do it.
Surg Infect (Larchmt), 11 (2010), pp. 289-294
[94]
B. Brandstrup, H. Tonnesen, R. Beier-Holgersen, E. Hjortsø, H. Ørding, K. Lindorff-Larsen, et al.
Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized, assesor-blinded multicenter trial.
[95]
W.R. Spanjersberg, J. Reurings, F. Keus, C.J. van Laarhoven.
Fast track surgery versus conventional recovery strategies for colorectal surgery.
Cochrane Database Syst Rev, 16 (2011), pp. CD007635
[96]
Y. Cerantola, M. Hübner, N. Grass, P.C. Bertrand, M. Schäfer, N. Demartines.
Immunonutrition in gastrointestinal surgery.
Br J Surg, 98 (2011), pp. 37-48
[97]
Y. Zhang, Y. Gu, T. Guo, Y. Li, H. Cai.
Perioperative immunonutrition for gastrointestinal cancer: a systematic review of randomized controlled trials.
Surg Oncol, 21 (2012), pp. e87-e95
[98]
S. Klek, M. Sierzega, P. Szybinski, K. Szczepanek, L. Scislo, E. Walewska, et al.
Perioperative nutrition in malnourished surgical cancer patients – a prospective, randomized, controlled clinical trial.
Clin Nutr, 30 (2011), pp. 708-713
[99]
A.B. Haynes, T.G. Weiser, W.R. Berry, S.R. Lipsitz, A.H. Breizat, E.P. Dellinger, et al.
A surgical safety checklist to reduce morbidity and mortality in a global population.
N Eng J Med, 360 (2009), pp. 491-499
[100]
T.L. Hedrick, J.A. Heckman, R.L. Smith, R.G. Sawyer, C.M. Friel, E.F. Foley.
Efficacy of protocol implementation on incidence of wound infection in colorectal operations.
J Am Coll Surg, 205 (2007), pp. 432-438
[101]
C. Pastor, A. Artinyan, M.G. Varma, E. Kim, L. Gibbs, J. Garcia-Aguilar.
An increase in compliance with the surgical care improvement project measures does not prevent surgical site infection in colorectal surgery.
Dis Colon Rectum, 53 (2010), pp. 24-30
[102]
T. Anthony, B.W. Murray, J.T. Sum-Ping, F. Lenkovsky, V.D. Vornik, B.J. Parker, et al.
Evaluating an evidence-based bundle for preventing surgical site infection. A randomized trial.
Arch Surg, 146 (2011), pp. 263-269
[103]
X. Serra-Aracil, M.I. García-Domingo, D. Parés, E. Espin-Basany, S. Biondo, X. Guirao, et al.
Surgical site infection in elective operations for colorectal cancer after the application of preventive measures.
Arch Surg, 146 (2011), pp. 606-612

Please cite this article as: Ruiz Tovar J, Badia JM. Medidas de prevención de la infección del sitio quirúrgico en cirugía abdominal. Revisión crítica de la evidencia. Cir Esp. 2014;92:223–231.

Copyright © 2013. AEC
Article options
Tools
es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos