Surgical Site Infections
PERIOPERATIVE STRATEGIES TO REDUCE / CONTROL THE RISK OF
SURGICAL SITE INFECTIONS
Muhammad Ihsan | August 12, 2020
Background
SSIs are potential complications associated with any type of surgical procedure. Although
SSIs are among the most preventable HAIs, they still represent a significant burden in
terms of patient morbidity and mortality and additional costs to health systems and
service payers worldwide. For these reasons, the prevention of SSI has received
considerable attention from surgeons and infection control professionals, health care
authorities, the media and the public. In particular, there is a perception among the public
that SSIs may reflect a poor quality of care.
SURGICAL SITE INFECTIONS
Surgical site infections are defined as infections that occur 30 days after surgery with no
implant, or within 1 year if an implant is placed and infection appears to be related to
surgery. Infections are classified as either incisional or organ/space infections to
differentiate those that occur at the incision site from those related to the organ or space
manipulated during surgery. Incisional infections are further classified as superficial or
deep.
CLASSIFICATION OF SSIs
SSIs are classified into incisional SSIs, which can be superficial or deep, and organ/space
SSIs, which affect the rest of the body other than the body wall layers (see the image
below). These classifications are defined as follows:
Superficial incisional SSI - Infection involves only skin and subcutaneous tissue of incision
Deep incisional SSI - Infection involves deep tissues, such as fascial and muscle layers; this
also includes infection involving both superficial and deep incision sites and organ/space
SSI draining through incision
Organ/space SSI - Infection involves any part of the anatomy in organs and spaces other
than the incision, which was opened or manipulated during operation.
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PREVENTION STRATEGIES OF SURGICAL SITE INFECTIONS:
APSIC Guidelines for Prevention of Surgical-Site Infection
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Perform surveillance of SSIs using accepted international methodology.
It is necessary for patients who will undergo surgery to have at least one preoperative
bath with soap (antimicrobial or nonantimicrobial).
A combination of mechanical bowel preparation and oral antibiotic preparation is
recommended for all elective colorectal surgery in adults.
Hair removal should be avoided unless hair interferes with the operative procedure.
If hair removal is necessary, a razor should be avoided, and an electric clipper should
be used. No recommendation is made regarding the timing of hair removal by
clipper.
Hospitals should evaluate their SSI rate, Staphylococcus aureus and methicillinresistant S aureus (MRSA) rates, and mupirocin resistance rate, if available, to
determine whether implementation of a screening program is appropriate.
Patients undergoing cardiothoracic and orthopedic surgery with known nasal
carriage of S aureus should receive perioperative intranasal application of mupirocin
2% ointment, with or without a combination of chlorhexidine body wash.
Surgical hand preparation is to be performed either by scrubbing with a suitable
antiseptic soap and water or by using a suitable alcohol-based hand rub (ABHR)
before sterile gown and gloves are donned. ABHRs used in surgical hand preparation
should comply with EN 12791 or ASTM E-1115 standards.
Where the quality of water used is not assured, use of an ABHR is recommended.
Alcohol-based skin antiseptic preparations should be used, unless contraindicated.
Administration of prophylactic antimicrobials should be performed only when
indicated. It should take place within 1 hour before incision for all antimicrobials
except vancomycin and fluoroquinolones, for which it should take place within
2 hours before incision. Redosing should be considered to maintain adequate tissue
levels on the basis of on agent half-life. A single dose of a prophylactic antimicrobial
is adequate for most surgical procedures.
Underweight patients undergoing major surgical procedures, especially oncologic
and cardiovascular operations, may benefit from the administration of oral or
enteral multiple nutrient-enhanced nutritional formulas for the purpose of
preventing SSI.
Preoperative hemoglobin A1c levels should be below 8%.
Maintain perioperative normothermia by using active warming devices.
Hemodynamic goal-directed therapy is recommended to reduce SSI.
There is insufficient evidence to recommend for or against saline irrigation of
incisional wounds before closure for the purpose of preventing SSI. Avoid using
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antimicrobial agents to irrigate incisional wounds before closure to reduce the risk
of SSI.
Where there are high SSI rates in clean surgical procedures in spite of basic
preventive measures, individual centers may consider the use of antimicrobialimpregnated sutures.
When using adhesive incise drapes for surgery, do not use non-iodophorimpregnated drapes; they may increase the risk of SSI. In orthopedic and cardiac
surgical procedures where adhesive incise drapes are used, consider using an
iodophor-impregnated incise drape, unless the patient has an iodine allergy or other
contraindication.
Careful evaluation of wound protectors must be done before the use of wound
protectors is introduced as a routine measure to reduce SSI.
Do not apply vancomycin powder into the surgical site for prevention of SSI.
Installation of laminar airflow is not required in new or renovated operating rooms
(ORs) to prevent SSI.
Primary vacuum dressings or negative-pressure wound therapy (ie, for cleancontaminated and contaminated surgical procedures) and silver-based dressings
have mixed results; individualized decisions on their use are suggested. Routine use
for prevention of SSI is not recommended.
CDC Guidelines for Prevention of Surgical-Site Infection
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Administer preoperative antimicrobial agents only when indicated by published
clinical practice guidelines, and time administration so that a bactericidal
concentration is established in serum and tissues when the incision is made (strong
recommendation; accepted practice).
Administer appropriate parenteral prophylactic antimicrobial agents before skin
incision in all cesarean section procedures (strong recommendation; high-quality
evidence).
In clean and clean-contaminated procedures, do not administer additional
prophylactic antimicrobial agent doses after the surgical incision is closed in the OR,
even in the presence of a drain (strong recommendation; high-quality evidence).
Do not apply antimicrobial agents (ie, ointments, solutions, or powders) to the
surgical incision with the aim of preventing SSI (strong recommendation; lowquality evidence).
Application of autologous platelet-rich plasma is not necessary for the prevention
of SSI (weak recommendation; moderate-quality evidence suggesting a trade-off
between clinical benefits and harms).
Consider the use of triclosan-coated sutures for the prevention of SSI (weak
recommendation; moderate-quality evidence).
Implement perioperative glycemic control, and use blood glucose target levels lower
than 200 mg/dL in patients with and without diabetes (strong recommendation;
high- to moderate-quality evidence).
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Maintain perioperative normothermia (strong recommendation; high- to moderatequality evidence).
For patients with normal pulmonary function undergoing general anesthesia with
endotracheal intubation, employ an increased fraction of inspired oxygen (FiO 2)
during the surgical procedure and after extubation in the immediate postoperative
period; to optimize tissue oxygen delivery, maintain perioperative normothermia
and adequate volume replacement (strong recommendation; moderate-quality
evidence).
Advise patients to shower or bathe the full body with either antimicrobial or
nonantimicrobial soap or an antiseptic agent on at least the night before the day of
the procedure (strong recommendation; accepted practice).
Perform intraoperative skin preparation with an alcohol-based antiseptic agent
unless this is contraindicated (strong recommendation; high-quality evidence).
Application of a microbial sealant immediately after intraoperative skin preparation
is not necessary for the prevention of SSI (weak recommendation; low-quality
evidence).
The use of plastic adhesive drapes with or without antimicrobial properties is not
necessary for the prevention of SSI. (weak recommendation; high- to moderatequality evidence).
Consider intraoperative irrigation of deep or subcutaneous tissues with aqueous
iodophor solution for the prevention of SSI; intraperitoneal lavage with aqueous
iodophor solution is not necessary in contaminated or dirty abdominal procedures
(weak recommendation; moderate-quality evidence).
Do not withhold transfusion of necessary blood products from surgical patients
undergoing prosthetic joint arthroplasty as a means of preventing SSI (strong
recommendation; accepted practice).
In clean or clean-contaminted prosthetic joint arthroplasties, do not administer
additional antimicrobial prophylaxis doses after the surgical incision is closed in the
OR, even in the presence of a drain (strong recommendation; high-quality
evidence).
WHO Guidelines on Surgical-Site Infection
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It is good clinical practice for patients to bathe or shower prior to surgery. Either
plain soap or an antimicrobial soap may be used for this purpose.
Patients undergoing cardiothoracic and orthopedic surgery with known nasal
carriage of S. aureus should receive perioperative intranasal applications of
mupirocin 2% ointment with or without a combination of chlorhexidine gluconate
(CHG) body wash.
Surgical antibiotic prophylaxis (SAP) should be administered prior to the surgical
incision when indicated (depending on the type of operation). The panel
recommends the administration of SAP within 120 min before incision, while
considering the half-life of the antibiotic.
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Preoperative oral antibiotics should be combined with mechanical bowel
preparation to reduce the risk of SSI in adult patients undergoing elective colorectal
surgery. Mechanical bowel preparation alone (without administration of oral
antibiotics) should not be used for the purpose of reducing SSI in adult patients
undergoing elective colorectal surgery.
In patients undergoing any surgical procedure, hair should either not be removed
or, if absolutely necessary, should be removed only with a clipper. Shaving is
strongly discouraged at all times, whether preoperatively or in the OR.
Alcohol-based antiseptic solutions are recommended based on CHG for surgicalsite skin preparation in patients undergoing surgical procedures.
Antimicrobial sealants should not be used after surgical-site skin preparation for the
purpose of reducing SSI.
Surgical hand preparation should be performed by scrubbing with either a suitable
antimicrobial soap and water or using a suitable alcohol-based handrub before
donning sterile gloves.
Consider the administration of oral or enteral multiple nutrient-enhanced
nutritional formulas for the purpose of preventing SSI in underweight patients who
undergo major surgical operations.
Do not discontinue immunosuppressive medication prior to surgery for the purpose
of preventing SSI.
Adult patients undergoing general anesthesia with endotracheal intubation for
surgical procedures should receive an 80% fraction of inspired oxygen
intraoperatively and, if feasible, in the immediate postoperative period for 2-6 hours
to reduce the risk of SSI.
Use triclosan-coated sutures for the purpose of reducing the risk of SSI, independent
of the type of surgery.
Preoperative antibiotic prophylaxis should not be continued in the presence of a
wound drain for the purpose of preventing SSI
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REFERENCES
1- CDC National and State Healthcare-Associated Infections Progress Report,
published October 2019, available from:
https://www.cdc.gov/hai/data/portal/progress-report.html
2- Awad, S.S., "Adherence to surgical care improvement project measures and
postoperative surgical site infections". Surgical Infection (Larchmt), 13(4): (2012):
234-7.
3- Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease Control
and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA
Surg. 2017;152(8):784–791. doi:10.1001/jamasurg.2017.0904
4- [Guideline] Berríos-Torres SI, Umscheid CA, Bratzler DW, et al, Healthcare
Infection Control Practices Advisory Committee. Centers for Disease Control and
Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA
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5- [Guideline] Surgical site infections: prevention and treatment.
NICE guideline[NG125]Published date: 11 April 2019
https://www.nice.org.uk/guidance/ng125
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et al. APSIC guidelines for the prevention of surgical site infections. Antimicrob
Resist Infect Control. 2019. 8:174. [Medline]. [Full Text].
7- [Guideline] Global guidelines for the prevention of surgical site infection. World
Health Organization. Available
at http://apps.who.int/iris/bitstream/10665/250680/1/9789241549882eng.pdf?ua=1. 2016; Accessed: November 25, 2019
8- [Guideline] Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ,
Gorbach SL, et al. Practice guidelines for the diagnosis and management of skin
and soft tissue infections: 2014 update by the infectious diseases society of
America. Clin Infect Dis. 2014 Jul 15. 59 (2):147-59. [Medline]. [Full Text].
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