World Health Organization · 2nd edition, 2018 (perioperative oxygenation recommendation revised December 2018) · 184 pages
Evidence-based recommendations for pre-, intra- and postoperative measures to prevent surgical site infections for all surgical patients worldwide.
- Issuer
- World Health Organization
- Edition
- 2nd edition, 2018 (perioperative oxygenation recommendation revised December 2018)
- Audience
- Surgical teams (surgeons, nurses, anaesthetists, technical staff), pharmacists, sterilization staff, IPC professionals, policy-makers, hospital managers
- Evidence
- GRADE-rated recommendations based on 27 systematic reviews; 13 strong and 16 conditional recommendations
- Reviewed
- 23 Oct 2026 · GMJ
What this guideline says
GMJ summary
These WHO guidelines provide 29 evidence-based recommendations covering 23 topics to prevent surgical site infection (SSI) across the pre-, intra- and postoperative periods. SSI is the most frequent health care-associated infection in low- and middle-income countries (affecting up to one-third of surgical patients) and the second most common in high-income countries. The guidelines address patient preparation, surgical antibiotic prophylaxis, intraoperative technique, environmental controls, and postoperative care.
All recommendations were developed using GRADE methodology following systematic reviews of the evidence. Thirteen recommendations are strong and sixteen are conditional. Key strong recommendations include: administering surgical antibiotic prophylaxis within 120 minutes before incision (but not prolonging it postoperatively); using chlorhexidine gluconate in alcohol for skin preparation; performing surgical hand preparation with antimicrobial soap or alcohol-based handrub; removing hair only with clippers if absolutely necessary (never shaving); and using triclosan-coated sutures.
The guidelines emphasize that SSI prevention requires integration of multiple measures throughout the surgical pathway. They are designed for universal application while considering resource availability, and include specific remarks on applicability to paediatric populations and implementation in resource-limited settings.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Administer surgical antibiotic prophylaxis within 120 minutes before incision when indicated; do NOT prolong prophylaxis after surgery completion (strong recommendation)
- Use alcohol-based chlorhexidine gluconate solution for surgical site skin preparation (strong recommendation)
- Perform surgical hand preparation with antimicrobial soap and water OR alcohol-based handrub before donning sterile gloves (strong recommendation)
- If hair removal is absolutely necessary, use clippers only; shaving is strongly discouraged at all times (strong recommendation)
- In patients undergoing cardiothoracic and orthopaedic surgery with known nasal carriage of S. aureus, apply mupirocin 2% ointment intranasally with or without chlorhexidine body wash perioperatively (strong recommendation)
- Consider using 80% fraction of inspired oxygen intraoperatively and for 2–6 hours postoperatively in adult patients under general anaesthesia with tracheal intubation (conditional recommendation, revised 2018)
- Use triclosan-coated sutures for SSI reduction independent of surgery type (conditional recommendation)
- Apply prophylactic negative pressure wound therapy on high-risk primarily closed surgical incisions in adults, considering resources (conditional recommendation)
Summary of core topics, research questions and recommendations for the prevention of surgical site infection
Table extracted from the guideline
| Topic | Recommendation | Strength | Quality of evidence |
|---|---|---|---|
| Preoperative bathing | Either plain soap or antimicrobial soap may be used; CHG-impregnated cloths: no recommendation due to very low quality evidence | Conditional | Moderate |
| Decolonization (mupirocin ± CHG) | Mupirocin 2% intranasal ± CHG body wash for nasal S. aureus carriers undergoing cardiothoracic/orthopaedic surgery | Strong | Moderate |
| Optimal timing for SAP | Administer SAP within 120 minutes before incision, considering antibiotic half-life | Strong | Moderate |
| Mechanical bowel preparation | MBP alone should NOT be used; consider oral antibiotics + MBP for elective colorectal surgery | Strong / Conditional | Moderate |
| Hair removal | Hair should not be removed or, if absolutely necessary, only with clippers; shaving strongly discouraged | Strong | Moderate |
| Surgical site preparation | Use alcohol-based antiseptic solutions based on chlorhexidine gluconate | Strong | Low to moderate |
| Antimicrobial skin sealants | Should NOT be used after surgical site skin preparation | Conditional | Very low |
| Surgical hand preparation | Scrub with antimicrobial soap and water OR use alcohol-based handrub before sterile gloves | Strong | Moderate |
| Perioperative oxygenation | Consider 80% FiO₂ intraoperatively and 2–6 hours postoperatively in adults under general anaesthesia | Conditional (revised 2018) | Moderate |
| Maintaining normothermia | Use warming devices in OR and during surgery | Conditional | Moderate |
| Intensive perioperative glucose control | Use protocols for intensive blood glucose control in diabetic and non-diabetic adults | Conditional | Low |
| SAP prolongation | Do NOT prolong SAP after operation completion | Strong | Moderate |
| Antimicrobial-coated sutures | Use triclosan-coated sutures independent of surgery type | Conditional | Moderate |
| Laminar airflow ventilation | Should NOT be used to reduce SSI risk in total arthroplasty | Conditional | Low to very low |
| Advanced dressings | Do NOT use advanced dressings over standard dressings on primarily closed wounds | Conditional | Low |
Source: World Health Organization, Global guidelines for the prevention of surgical site infection, second edition. Reproduced in summary form.
What changed in this edition
Versus the previous edition
- Recommendation on perioperative oxygenation (80% FiO₂) revised in 2018 from strong to conditional following updated systematic review on effectiveness and new safety review; GDG membership expanded to include eight additional anaesthetists for this re-evaluation
- Second edition (2018) includes 29 recommendations covering 23 topics, representing comprehensive expansion and update of evidence since first scoping in 2013
From the guideline
Verbatim
“The panel recommends that surgical antibiotic prophylaxis should be administered prior to the surgical incision when indicated (depending on the type of operation).”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As chair of Georgia's Public Health Institute and former WHO consultant, I have seen firsthand how surgical site infections drain resources from our hospitals and harm patients who have often waited months for procedures under the universal coverage programme. This WHO guideline matters because it gives our surgeons, infection control teams, and hospital managers a unified, evidence-based framework—many of our facilities still follow Soviet-era practices or inconsistent protocols borrowed from different countries. The single recommendation I would stress to Georgian colleagues is the strong evidence against prolonging antibiotic prophylaxis after surgery: we see this wasteful and harmful practice daily in Tbilisi teaching hospitals and regional centres, driven by fear of infection but actually fuelling the antimicrobial resistance crisis we are fighting through the National Action Plan. The realistic implementation caveat is post-discharge surveillance—with patients travelling long distances from referral centres back to mountain villages and limited telephone follow-up infrastructure, we will need to adapt the 30-day surveillance methods, perhaps through integration with the rural ambulatory network and training of community nurses, before we can reliably benchmark our SSI rates against the European data this guideline references.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 23 Oct 2026
Applicability
Georgia and the South Caucasus
These guidelines have direct relevance for Georgia and the South Caucasus, where surgical volume is increasing with economic development and universal health coverage expansion. Georgia’s 2013 UHC programme has increased access to elective and emergency surgery, making SSI prevention protocols essential for quality and cost control. The guidelines’ emphasis on low-cost interventions (proper timing of antibiotic prophylaxis, alcohol-based hand hygiene, clippers instead of razors) is particularly applicable to district hospitals across the region. However, national implementation programmes will need to address specific constraints: establishing post-discharge surveillance in rural areas with limited follow-up capacity; ensuring cold-chain and timely availability of prophylactic antibiotics in remote surgical facilities; and validating adapted SSI definitions and surveillance methods feasible for Georgian hospitals participating in the National Centre for Disease Control’s HAI surveillance network, which currently has limited SSI reporting compared to European systems.
Questions this guideline answers
Quick answers
When exactly should surgical antibiotic prophylaxis be given?
Administer SAP within 120 minutes before the surgical incision, taking into account the half-life of the antibiotic. Do not continue antibiotics after the operation is completed—prolongation does not reduce SSI and contributes to antimicrobial resistance.
Should we shave the surgical site before operation?
No. Hair should either not be removed at all or, if absolutely necessary for the procedure, removed only with clippers. Shaving with a razor is strongly discouraged at all times (preoperatively or in the operating room) as it increases SSI risk.
What is the best antiseptic solution for preparing the skin before incision?
Use alcohol-based antiseptic solutions containing chlorhexidine gluconate (CHG) for surgical site skin preparation. These are more effective than aqueous solutions or povidone-iodine preparations.
Do we need to continue antibiotics if a surgical drain is left in place?
No. Preoperative antibiotic prophylaxis should not be continued in the presence of a wound drain for the purpose of preventing SSI. Remove the drain when clinically indicated; no specific evidence supports optimal timing for drain removal to prevent SSI.
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- Issuer
- World Health Organization
- Type
- Guideline
- Edition
- 2nd edition, 2018 (perioperative oxygenation recommendation revised December 2018)
- Replaces
- First scoping and recommendations issued November 2016
- Status
- Current
- Published
- 2023-07-17
- Languages
- English (original); translations available via WHO regional offices
- Scope
- All surgical procedures in all age groups (some recommendations not proven or not applicable in paediatrics as specified)
- Audience
- Surgical teams (surgeons, nurses, anaesthetists, technical staff), pharmacists, sterilization staff, IPC professionals, policy-makers, hospital managers
- Pages
- 184
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 978-92-4-155047-5
- Evidence
- GRADE-rated recommendations based on 27 systematic reviews; 13 strong and 16 conditional recommendations
- Next review
- At least every 5 years following identification of new evidence (per WHO guideline procedures)
- Record history
- Created 23 Oct 2026 · updated 23 Oct 2026 · next check Apr 2027
World Health Organization. Global guidelines for the prevention of surgical site infection, second edition. Geneva: World Health Organization; 2018. ISBN 978-92-4-155047-5.GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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