Surgical site infections (SSIs) account for a large proportion of healthcare-associated infections and are a worldwide problem in terms of patient and medical burden. The Japanese Society for Surgical Infection published the “Guidelines for the prevention, detection, and management of gastroenterological surgical site infection, 2018” in 2018. We compared this guideline with those of other countries, focusing on the differences in the content of the recommendations and the method of development. As a result, we found that this guideline is the most reliable guideline in Japan because the recommendations are based on the latest evidences and the current Japanese situation. On the other hand, this guideline does not cover surgery for peritonitis in which infection has already been established, so we hope that these areas will be covered when the guideline is revised in about 4 to 5 years.

“Practical guideline for operative medicine” issued by Japanese Association for Operative Medicine and “Guideline of Perioperative management for prevention of SSI in digestive surgery 2018” issued by Japan Society for Surgical Infection were compared. Difference of recommendations were found in intraoperative redosing and duration of antimicrobial prophylaxis, drugs for preoperative skin antisepsis, use of incise drape, intraoperative exchange of gloves and double gloving, use of new instruments for abdominal closure, wound irrigation, intraabdominal irrigation, perioperative glucose control, and perioperative hyperoxygenation. Recommendations of guidelines were basically decided based on the evidence, however, they were not always the same. Each institution has to select the recommendations after strict investigation into the reasons and the background of each recommendation.

Background: Antimicrobial-coated suture has recently become well known for preventing surgical site infection (SSI). However, the evidence and recommendations from some organizations remains controversial. Therefore, we conducted a systematic review and meta-analysis to analyse the efficacy of antimicrobial-coated sutures for preventing SSIs in gastrointestinal surgery. Methods: We performed a systematic literature review. We included studies defined as randomized controlled trials（RCTs）and observational studies (OBSs) for the prevention of SSIs and a reduction in the length of hospital stays during gastrointestinal surgery. Results: A total of 15 studies including 10 RCTs and 5 OBSs were selected. In the results of the RCTs, antimicrobial-coated sutures were superior at reducing the incidence of incisional SSI (RR 0.68, 95% CI: 0.48–0.95, P=0.03). The superior effect of antimicrobial-coated sutures was also found in OBSs (OR 0.4, 95% CI: 0.3-0.54, P＜0.001). Although the superior effect of antimicrobial-coated suture was found in poly-filament suture material (RR 0.45, 95%CI: 0.26-0.77, P＝0.004), that was not found in poly-filament suture material (RR 0.82, 95%CI: 0.57-1.18, P=0.28). The mean length of hospital stays was similar. Conclusion: Antimicrobial-coated sutures are significantly more efficacious at preventing SSIs during either gastrointestinal or colorectal surgery. However, that efficacy was not found in the mono-filament suture material.

Anti-tumor necrosis factor (TNF) alpha agent treatment is effective for ulcerative colitis (UC) and Crohn’s disease (CD). We conducted a systematic review and meta-analysis examining the prevention of surgical site infection（SSI）associated with surgery for UC and CD in patients using anti-TNF agent. (Methods) We performed a systematic literature review until June 2019 and performed meta-analysis. (Results) 13 studies for UC and 16 studies for CD were included. Anti-TNF agent use in patients with UC was not associated with the incisional SSI (odds ratio (OR) 1.04, 95％ confidence interval (CI) (0.47-2.32)) or organ/space SSI (OR 1.85, 95% CI (0.82-4.20)). Anti-TNF agent use in patients with CD was not associated with the incisional SSI (OR 0.98, 95% CI (0.52-1.83)) or organ/space SSI incidence (OR 1.08, 95% CI (0.79-1.48)). (Conclusion) We observed a nonsignificant association between preoperative anti-TNF agent use and SSI in surgery for UC and CD.

Bundle approach would be useful for prevention of surgical site infections (SSIs). However, it is difficult to implement all the measures that have evidence at the institute. In Aichi Medical University Hospital, we have not been able to implement all the measures for SSI prevention. We have selected the measures that are have evidence for SSI prevention, and have put into practice according to the current state of our institute. At first, we have analyzed SSI of patients who underwent rectal resection at Aichi Medical University Hospital from January 2016. As a result, it became clear that there have been a lot of surface SSI infections in 2017. We have decided to introduce closed wound surgical instrument set for the purpose of exchanging instruments. After introducing closed wound surgical instrument set, the incidence of SSI in patients with receiving colorectal operation decreased from 22.6% (January 2017 to September 2017) before the introduction of device replacement to 9.6% (October 2017 to December 2018) (P=0.06). From our experience, we have concluded that the analysis of current situation of each institute would be important, and that implementation one by one according to the surveillance data importance would be also useful for reducing SSI.

The clinical efficacy of the measures recommended in the SSI prevention guidelines can be proven only when SSIs have decreased as a result of the measures taken. In order to show a decrease in SSI, continuous monitoring of SSI, or SSI surveillance, is necessary. In this sense, SSI prevention measures and SSI surveillance should work together like two wheels of a car to achieve the desired outcome for patients, the decrease in SSI. The method of SSI surveillance conducted in Japan has been standardized. Using data from the JANIS system, the frequency of SSIs before and after the publication of the guideline, hepatobiliary and pancreatic surgeries showed a significant decreasing trend after the publication of the guideline, while it remained unchanged before the publication. On the other hand, colon and rectal surgeries showed a significant decreasing trend in SSI even before publication and steadily decreased after publication. In the case of hepatobiliary and pancreatic surgeries, which are complicated and relatively difficult to standardize, the guideline may have standardized SSI measures and turned the downward trend in SSI occurrence.