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Overcoming Cultural Barriers to SSI Prevention Guidelines

Guidelines represent consensus – in thinking, expertise and practice. They, in theory, reflect communal alignment. In the area of Surgical Site Infection (SSI) prevention, evidence-based guidelines seek to minimise risks, improve health outcomes and reduce unnecessary variations in care throughout the surgical continuum.

by Dr Keita Morikane, M.D., PhD

Throughout the past 30 years in my roles as a general surgeon and an infection expert, I’ve witnessed significant improvements in SSI prevention measures, but it is undeniable that more needs to be done to truly eliminate SSIs, particularly in Asia-Pacific where countries continue to face barriers to the implementation of guidelines.


Examining the Current SSI Landscape

SSI, one of the most commonly reported Healthcare Acquired Infections (HAI), pose a significant challenge to healthcare institutions globally, leading to high mortality rates, extended hospital stays and the required use of additional resources. According to a retrospective study led by the Japan Society for Surgical Infection (JSSI), which investigated the impact of SSI on patients’ hospital length of stay (LOS) and healthcare costs following abdominal surgery, SSI resulted in about 18 days of excess LOS and approximately US$6,600 in additional healthcare costs.1

Due to the severity of SSI-related complications, government bodies and surgical associations are taking action to prevent SSIs. This involvement has become increasingly important with the growth in surgical volumes, which is estimated to have risen by approximately 38 percent between 2004 and 2012.2 This puts millions of individuals across the globe at risk of developing SSI.

Though the risk remains high, studies have shown that up to 60 percent of SSIs are preventable when evidence-based guidelines are followed.3 Acknowledging both a need and opportunity, the World Health Organization (WHO) launched the first ever evidence-based guidelines on the prevention of SSIs in 2016, collating a series of recommendations from leading global experts.

This has also translated to the development of regional guidelines – efforts that I have personally sought to stand behind and champion. In 2018, the Asia-Pacific Society of Infection Control (APSIC) published guidelines for the prevention of SSIs, providing practical evidence-based recommendations to ensure high standards in pre-, peri- and post-operative procedures.4 Particularly for resource-constrained countries, the key takeaway is to drive gap analysis in existing practices and implement a process improvement plan to achieve positive results.

However, in my experience travelling across the Asia-Pacific region, there is still a significant gap in putting guidelines to standard practice – and even when they are successfully implemented, institutions face challenges in sustaining preventive measures.


Reaching Consensus and Localising Guidelines

Collectively, there is greater understanding of the need for SSI prevention amongst the healthcare community in Asia-Pacific. This is, in large part, due to the impact it’s having on patients; in some countries, SSI mortality rate can reach as high as 46 percent.5 However, there remains a lack of adequate response and implementation of guidelines at the national level.

Cultural factors are one of the key obstacles in the adoption of SSI guidelines, particularly for a region as diverse as Asia-Pacific, where different customs, languages, beliefs and professional practices intertwine. While global evidence-based guidelines are relevant for application across the region, it is vital that healthcare associations and surgeons consider the unique variations stemming from each country to ensure continued engagement in the long run.

That said, localisation isn’t a novel notion and has, indeed, been practiced for years. Most recently this year, China established guidelines for the prevention of SSIs, focusing on how bacterial growth can be minimised across the episode of patient care.

JSSI, whose membership has grown to close to 2,000 over the past 30 years, recently published localised guidelines to manage the risk of SSIs following gastrointestinal (GI) procedures, in Japanese. By driving conversations and providing a guide to local healthcare professionals, a fall in SSI incidence following GI surgeries can be accomplished.

Smaller nations in Southeast Asia, such as Malaysia, Thailand and the Philippines, have also developed localised guidelines and consensus. The next step for these countries is to establish nation-wide SSI surveillance systems.


Where Culture and Implementation Collides: Healthcare Player Buy-In

Beyond localisation, the actual execution of guidelines ultimately comes down to surgeons and healthcare professionals on the frontlines. While we have the resources required and innovative solutions on the market, such as Plus Antibacterial Suture – the only triclosan-coated sutures made available by Ethicon globally, surgeon participation is crucial to drive real change.

Through my work with physicians over the years, including surgeons, I have observed that there are a number of professionals who believe in the effectiveness of evidence-based guidelines published from Western countries, whereas others are resistant to the recommended practice.

In order to drive engagement, we need to leverage internal data highlighting that the proposed guidelines can effectively mitigate SSI rates in local settings. By presenting the hard facts, we can meaningfully shift surgeons’ mindsets and nudge them to be more receptive towards evidence-based practices, starting from the adoption of simple measures such as hand hygiene.

At the end of the day, it’s about improving patient outcomes. Most doctors I’ve encountered seek to do just this – improve the health and quality of life for their patients. For me, strengthening the relationship between guidelines and improved patient outcomes is how we increase implementation.


Prioritising Surveillance and Deepening Insights

It is clear that accurate data plays a crucial role in encouraging adoption within local hospitals. This can only be supported with a comprehensive surveillance programme.

Surveillance has a sentinel effect on lowering SSI rates, prompting for performance to improve when those involved are aware their behaviour is being monitored and evaluated.6 Experts who attended the first-ever Ethicon Care+ APAC Masters SSI Prevention Symposium held in 2019 similarly agreed that surveillance programmes are effective in reducing SSIs as it allows them to identify issues and implement corrections immediately.

In a bid to create a comprehensive SSI database in Japan, the Japanese Nosocomial Infections Surveillance (JNIS) system was established in 1998 by the Japanese Society for Infection Control and Prevention, after adopting the U.S. National Nosocomial Infection Surveillance System (NNIS). Following which, the Japanese Ministry of Health and Welfare started a nation-wide SSI surveillance programme in 2002 and a study group was founded in the same year to provide support and implement activities to further spread and enhance the quality of such surveillance initiatives in the country.7 Japan has since created a robust surveillance system,7 so as to comprehensively monitor the landscape of SSIs in the country.

It is clear that Japan has come a long way since the lacking state of infection control in the 1980s. We are also seeing improved participation rates among surgeons as well as the development of localised guidelines, thus providing a model for other nations to look towards. [APBN]


  1. Kusachi, S., Kashimura, N., Konishi, T., Shimizu, J., Kusunoki, M., Oka, M., … Sumiyama, Y. (2012). Length of Stay and Cost for Surgical Site Infection after Abdominal and Cardiac Surgery in Japanese Hospitals: Multi-Center Surveillance. Surgical Infections, 13(4), 257–265.
  2. Weiser, T.G., Haynes, A.B., Molina, G. et al. (2016). Size and distribution of the global volume of surgery in 2012. Bulletin of the World Health Organization, 94(3), 201–209F.
  3. Meeks, D. W., Lally, K. P., Carrick, M. M., Lew, D. F., Thomas, E. J., Doyle, P. D., & Kao, L. S. (2011). Compliance with guidelines to prevent surgical site infections: As simple as 1-2-3? The American Journal of Surgery, 201(1), 76–83.
  4. Ling, M. L., Apisarnthanarak, A., Abbas, A., Morikane, K., Lee, K. Y., Warrier, A., & Yamada, K. (2019). APSIC guidelines for the prevention of surgical site infections. Antimicrobial Resistance & Infection Control, 8(1).
  5. Ling, M. L., Apisarnthanarak, A., & Madriaga, G. (2015). The Burden of Healthcare-Associated Infections in Southeast Asia: A Systematic Literature Review and Meta-analysis. Clinical Infectious Diseases, 60(11), 1690–1699.
  6. Morikane, K., Nishioka, M., Tanimura, H., Noguchi, H., Konishi, T., & Kobayashi, H. (2002). Using Surveillance Data to Direct Infection Control Efforts to Reduce Surgical-Site Infections Following Clean Abdominal Operations in Japan. Infection Control & Hospital Epidemiology, 23(07), 404–406.
  7. Morikane, K., Honda, H., Yamagishi, T., Suzuki, S., & Aminaka, M. (2014). Factors Associated with Surgical Site Infection in Colorectal Surgery: The Japan Nosocomial Infections Surveillance. Infection Control & Hospital Epidemiology, 35(06), 660–666.

About the Author

Dr. Keita Morikane, M.D., PhD

Dr. Morikane currently serves as the Director of Division of Infection Control and Clinical Laboratory at Yamagata University Hospital. Having graduated from the University of Tokyo in 1989, Dr. Morikane worked as a surgeon for 14 years, then as an epidemiologist for 5 years at the Japanese National Institute of Infectious Disease.

He also serves as an Executive Board Member and Chair of Japan Society for Surgical Infection’s International Affairs Committee, as well as a Board Member and Chair of the Educational Committee at Japanese Society for Infection Prevention and Control.

He has authored / co-authored more than 35 peer-reviewed publications and made numerous presentations at conferences in Japan as well as abroad. Dr. Morikane most recently participated in the first-ever Care+ Asia-Pacific Masters SSI Prevention Symposium, organised by Ethicon, which brought together a consortium of international experts to strategise how Asia-Pacific can advance the adoption and implementation of global guidelines, as well as institute surveillance methods to reduce the risk of SSIs.