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Surgical Site Infection: Prevention and Treatment [A] Evidence Review for Effectiveness of Nasal Decolonisation in Prevention of Surgical Site Infection

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Surgical Site Infection: Prevention and Treatment [A] Evidence Review for Effectiveness of Nasal Decolonisation in Prevention of Surgical Site Infection National Institute for Health and Care Excellence Guideline version (FINAL) Surgical site infection: prevention and treatment [A] Evidence review for effectiveness of nasal decolonisation in prevention of surgical site infection NICE guideline NG125 Evidence reviews April 2019 FINAL These evidence reviews were developed by NICE Guideline Updates Team FINAL Error! No text of specified style in document. Disclaimer The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian. Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties. NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn. Copyright © NICE 2019. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3394-5 FINAL Contents Effectiveness of nasal decolonisation in the prevention of surgical site infection ........ 6 Review question ............................................................................................................. 6 Introduction ........................................................................................................... 6 Table 1 PICO: Does the use of nasal decolonisation to eliminate Staphylococcus aureus (alone or in combination with other interventions) affect the rate of surgical site infection? ............................... 6 Methods and process ............................................................................................ 7 Clinical evidence ................................................................................................... 8 Summary of clinical studies included in the evidence review ................................. 8 Quality assessment of clinical studies included in the evidence review ............... 12 Economic evidence ............................................................................................. 12 Summary of studies included in the economic evidence review ........................... 12 Economic model .................................................................................................. 14 Evidence statements ........................................................................................... 17 The committee’s discussion of the evidence ........................................................ 20 Appendices ........................................................................................................................ 27 Appendix A – Review protocols .................................................................................... 27 Appendix B- Methods ................................................................................................... 37 Priority screening ................................................................................................. 37 Evidence of effectiveness of interventions ........................................................... 38 Health economics ................................................................................................ 41 Appendix C – Literature search strategies .................................................................... 43 Appendix D – Clinical evidence study selection ............................................................ 49 Appendix E – Clinical evidence tables .......................................................................... 50 E.1 Bode (2010) .................................................................................................. 50 E.2 Kalmeijer (2002) ............................................................................................ 52 E.3 Konvalinka (2006) ......................................................................................... 56 E.4 Perl (2002) .................................................................................................... 58 E.5 Philips (2014) ................................................................................................ 62 E.6 Segers (2006) ............................................................................................... 65 E.7 Sousa (2016) ................................................................................................ 68 E.8 Suzuki (2003) ................................................................................................ 70 E.9 Tai (2013) ..................................................................................................... 73 Appendix F – Forest plots ............................................................................................. 76 F.1 Mupirocin versus placebo .............................................................................. 76 F.2 Mupirocin versus no nasal decontamination .................................................. 81 F.3 Mupirocin versus 5% Povidone Iodine ........................................................... 82 F.4 Mupirocin + CH wash versus no treatment .................................................... 83 4 FINAL F.5 Mupirocin + CH wash versus placebo ........................................................... 84 F.6 Mupirocin (with or without CH was) versus all non-active interventions ......... 86 F.7 Chlorhexidine + CH wash versus placebo ..................................................... 86 Appendix G – GRADE tables ........................................................................................ 89 G.1 Mupirocin versus placebo ............................................................................. 89 G.2 Mupirocin versus no nasal decontamination ................................................. 93 G.3 Mupirocin versus 5% povidone iodine ........................................................... 94 G.4 Mupirocin and chlorhexidine body wash vs No nasal decontamination ......... 95 G.5 Mupirocin and chlorhexidine body wash vs placebo ...................................... 97 G.6 Mupirocin (with or without chlorhexidine body wash) vs all non-active interventions ............................................................................................ 98 G.7 Chlorhexidine vs. placebo ............................................................................. 99 Appendix H – Economic evidence tables .................................................................... 101 Appendix I – Economic evidence study selection ....................................................... 106 Appendix J – Excluded studies ................................................................................... 107 Clinical studies .................................................................................................. 107 Economic studies .............................................................................................. 112 Appendix K – Research recommendations ................................................................. 115 1. What is the clinical effectiveness of preoperative nasal decolonisation using mupirocin in combination with a chlorhexidine body wash in the whole population? .................................................................................. 115 2. What is the contribution to clinical effectiveness of the timing of nasal decolonisation and body wash for the prevention of surgical site infection? ............................................................................................... 116 3. Is the use of chlorhexidine body wash associated with increased antimicrobial resistance? ........................................................................ 117 4. What is the effectiveness of decolonisation using alternative interventions in combination with nasal decolonisation in the prevention of surgical site infections when chlorhexidine is contraindicated? .......... 118 Appendix L - References ............................................................................................ 119 Included studies ................................................................................................ 119 Excluded studies ............................................................................................... 120 5 FINAL Effectiveness of nasal decolonisation in the prevention of surgical site infection Effectiveness of nasal decolonisation in the prevention of surgical site infection Review question Does the use of nasal decolonisation to eliminate Staphylococcus aureus (alone or in combination with other interventions)
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