European Guideline on Pre‐Operative Prevention of Surgical Site Infections Following Digestive Surgery: A Joint Update of the WHO SSI Guideline for Gastrointestinal Surgery by UEG, ESCP, EAES, and SIS‐E

UEG/ESCP · 2025 · Europe

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Authors: UEG/ESCP/EAES/SSI‐E SSI Prevention Working Group
Title: European Guideline on Pre‐Operative Prevention of Surgical Site Infections Following Digestive Surgery: A Joint Update of the WHO SSI Guideline for Gastrointestinal Surgery by UEG, ESCP, EAES, and SIS‐E
Journal: United European Gastroenterology Journal, 2025
DOI: 10.1002/ueg2.70128
Licence: CC BY 4.0
Changes: Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC12704574

Licence statement of the original publication

This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.

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Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Lay Summary

We suggest that corticosteroids and anti‐TNF medication (medication i.e. used to decrease inflammation and treat conditions such as inflammatory bowel disease) be stopped before surgery.

Recommendations

The panel suggests the use of alcohol‐based chlorhexidine gluconatevery low certainty of evidence
The panel suggests that corticosteroid medication should be discontinued pre‐operativelyvery low certainty of evidence
The panel suggests anti‐TNF medication should be discontinued pre‐operativelyvery low certainty of evidence

Implications for Policy Makers

The panel suggests the use of alcohol‐based chlorhexidine gluconate. There are no concerns with regards to the use of CHG and health equity across Europe, and no major barriers to the implementation of the use of CHG as skin preparation for clean, clean‐contaminated or contaminated gastrointestinal, hepatobiliary and pancreatic surgical procedures. The slightly higher cost of CHG compared to PVI is off‐set by the significant savings in reducing SSI incidence. Alcohol‐based CHG should be made available in operating theatres to help reduce SSI rates.
The panel suggests that corticosteroid medication should be discontinued pre‐operatively. Given the favourable impact of steroid weaning on postoperative infectious complications, the intervention will likely be acceptable to key stakeholders. Policy makers must ensure that appropriate infrastructure is in place to allow identification of those patients taking corticosteroids pre‐operatively and allow sufficient time for corticosteroids to be weaned or stopped (where possible) prior to surgery. Policy makers should put processes in place to facilitate multidisciplinary working, as patients' corticosteroids are likely initiated or managed by another specialist who should be involved in the discussions about stopping the medication.
The panel suggests anti‐TNF medication should be discontinued pre‐operatively. Policy makers must ensure appropriate infrastructure is in place to allow operative interventions to take place at the nadir of the medication (4‐weeks for Infliximab; so, missing a dose for those on a 4‐weekly regime or between doses for those on an 8‐weekly regime. For Adalimumab, usually a dose is missed, as timing between doses is usually 2‐weeks). There must be infrastructure in place to allow patients to be restarted on their medication 4 weeks post‐operatively if suitable, to prevent multiple missed doses of medication. Policy makers should put processes in place to facilitate multidisciplinary working, as patients' anti‐TNF medication is likely to be initiated or managed by another specialist who should be involved in the discussions about stopping the medication.

Implications for Healthcare Professionals

The panel suggests the use of alcohol‐based chlorhexidine gluconate. While alcohol‐based chlorhexidine gluconate has been shown to decrease overall SSI rates, it is important to remember that it cannot be used in all situations encountered when conducting gastrointestinal surgery. Alcohol‐based preparations cannot be used on a mucous membrane (e.g., intestinal stoma, perineum) or on an open wound. Alternative aqueous preparations must be used for those areas where a mucous membrane or open wound is present. If suitable, aqueous betadine could be used for the mucous membranes as its colouring allows for easy identification of the limit of preparation, with alcohol‐based chlorhexidine being used for the rest of the preparation, up to the limit of the betadine. However, there are no data to suggest that either aqueous chlorhexidine or aqueous betadine is superior to the other, so choice can be surgeons' preference.
The panel suggests that corticosteroid medication should be discontinued pre‐operatively. The application of the recommendation should be contextualised, and a tailored approach should be used considering each patient's individual circumstances and type of surgical procedure. Although the majority of this data involves patients with inflammatory bowel disease (IBD), the recommendation is also likely to apply to patients without IBD who take corticosteroids for other medical conditions. It may be there are concerns in disease recurrence or relapse when steroids are weaned in IBD patients. Therefore, the benefit of controlling the disease with corticosteroids (or alternative medication) against the risk of SSI needs a careful balance. The trade‐off may be variable depending on clinicians' and patients' decisions. The data from this guideline could serve as benchmarks for the risk/benefit evaluation.
The panel suggests anti‐TNF medication should be discontinued pre‐operatively. Taking into consideration the very low certainty of evidence and the need to balance between the potential risk of SSIs and disease flares, the panel suggests, in patients undergoing elective surgery, to plan the operation at the Infliximab nadir, which is 4 weeks after the last infusion (time between doses: 8 weeks). Patients usually recover after 4 weeks, when the next dose is administered, and no treatment interruption occurs. This can both reduce the risk of flares and ensure surgery is distant enough from the last dose to reduce other infectious risks. In patients taking Adalimumab, usually a dose or two is missed as the period between injections is shorter (1 or 2 weeks). It is unclear if this has any effect on disease recurrence, but it is unlikely.

Abstract

This is an update of the WHO SSI guideline published in 2018, focussing on areas pertinent for gastrointestinal (GI) surgery and hepatobiliary and pancreatic (HBP) surgical procedures. Based on new information and appraisal of current evidence, the following recommendations can be suggested: During skin preparation, we suggest using alcohol‐based chlorhexidine for clean, clean‐contaminated, and contaminated GI and HBP surgical field preparation in the absence of a mucous membrane (e.g., stoma, genitalia, anus). Preoperatively, we suggest that corticosteroids and anti‐TNF medication be discontinued. No recommendations could be made on the following comparisons, given the paucity of high‐quality evidence and panel discussion not favouring one intervention over the other based on clinical experience: 2%–3% chlorhexidine gluconate versus aqueous povidone‐iodine for surgical field preparation. 4%–5% chlorhexidine gluconate versus aqueous povidone‐iodine for surgical field preparation. Aqueous chlorhexidine gluconate versus aqueous povidone‐iodine for surgical field preparation Pre‐operative dexamethasone in single‐dose versus no pre‐operative dexamethasone for patients undergoing GI surgery. Discontinuing Vedolizumab preoperatively versus continuing Vedolizumab preoperatively for patients undergoing GI surgery. Discontinuing Ustekinumab preoperatively versus continuing Ustekinumab preoperatively for patients undergoing GI surgery.

Contents of the original publication

The section headings of the original.

Lay Summary
Scope and Purpose
Objectives
Methods
Research Questions
Target Population
Target Users, Preferences and Views
Methodological Support
Stakeholder Involvement
Rating the Importance of Outcomes
Setting the Minimally Important Differences
Search Methods
Study Selection and Evidence Selection Criteria
Strengths and Limitations of Evidence
Evidence to Decision Framework and Developing Recommendations
Wording of Recommendations
Results
Interventions and Comparisons
Search Results
Subgroup Analysis
Formulation of Recommendations
Recommendations
Justifications
Discussion
Implications for Policy Makers
Implications for Healthcare Professionals
Implications for Patients
Implications for Researchers
Barriers and Facilitators
Implementation and Dissemination
Monitoring/Auditing Criteria
Updating Procedure
Consent
Supporting information
Contributor Information

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