Surgical site infections: does one glove fit all?

We congratulate the ChEETAh trial group on a well performed, highly relevant trial.1Ademuyiwa AO Adisa AO Bhangu A et al.Routine sterile glove and instrument change at the time of abdominal wound closure to prevent surgical site infection (ChEETAh): a pragmatic, cluster-randomised trial in seven low-income and middle-income countries.Lancet. 2022; 400: 1767-1776Summary Full Text Full Text PDF PubMed Scopus (9) Google Scholar However, we do not entirely agree with their conclusion. For power calculations, a 4% absolute difference in surgical site infections (SSIs) was considered minimally clinically important. Although highly statistically significant, the clinical relevance of the observed 2·8% absolute reduction in SSIs is unclear. The number needed to treat (NNT) to avoid one SSI is 36, which might not justify the intervention. Most incisional SSIs are superficial2Rattanakanokchai S Eamudomkarn N Jampathong N Luong-Thanh B-Y Kietpeerakool C Changing gloves during cesarean section for prevention of postoperative infections: a systematic review and meta-analysis.Scientific Reports. 2021; 114592Crossref PubMed Scopus (4) Google Scholar and easily treated with bedside drainage, causing minimal morbidity. The proportion of superficial and deep incisional SSIs according to the Centers for Disease Control and Prevention–National Healthcare Safety Network classification should therefore be reported.3Centers for Disease Control and Prevention–National Healthcare Safety NetworkSurgical site infection event (SSI).https://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdfDate: 2022Date accessed: November 16, 2022Google Scholar The between-group difference in dirty wounds (2·5%) might partly explain the 2·8% reduction in SSIs. Further, the handling of probable multicollinearity problems among adjustment variables in the subgroup analysis is not described. According to figure 2 of the ChEETAh trial, patients with emergency interventions, midline incisions, and contaminated dirty wounds accounted for most of the reduction in SSIs. The subgroup analysis (supplementary figure 9 of the ChEETAh trial) indicates an NNT above 100 to prevent one SSI in a clean-contaminated elective setting. Therefore, it seems inappropriate to recommend the intervention for all abdominal closures, especially for elective laparoscopic procedures with little contamination. Changing gloves and sterilising extra instruments increases the CO2 footprint, with negative environmental effects. Considering the emerging focus on sustainable surgery, we encourage the authors to identify subgroups of patients who benefit with clinical relevance from the proposed intervention and to specify the proportions of superficial and deep incisional SSIs. We declare no competing interests. Routine sterile glove and instrument change at the time of abdominal wound closure to prevent surgical site infection (ChEETAh): a pragmatic, cluster-randomised trial in seven low-income and middle-income countriesThis trial showed a robust benefit to routinely changing gloves and instruments before abdominal wound closure. We suggest that it should be widely implemented into surgical practice around the world. Full-Text PDF Open AccessSurgical site infections: does one glove fit all? – Authors' replyWe thank Johannes Kurt Schultz and colleagues for their Correspondence about the ChEETAh trial.1 We encourage readers to consider both relative and absolute risk reduction when making decisions about practice change. The absolute risk of surgical site infection (SSI) varies substantially from patient to patient and operation to operation, so considering the absolute effect size could lead to underestimation or overestimation of relative clinical effectiveness. Our interaction analysis showed no significant difference in effectiveness between key subgroups (eg, emergency vs elective, clean–contaminated vs contaminated–dirty), suggesting that the benefit observed was consistent across the study population. Full-Text PDF