Strategies to Prevent Surgical Site Infections in Acute-Care Hospitals
Publication Date: May 3, 2023
Last Updated: November 15, 2023
Recommendations
Table 1. Recommendations to Prevent Surgical Site Infections (SSIs)
Essential Practices
Should be adopted by all acute-care hospitals unless a clear and compelling rationale for an alternative approach is present
1.
Administer antimicrobial prophylaxis according to evidence-based standards and guidelines. (H)
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2.
Use a combination of parenteral and oral antimicrobial prophylaxis prior to elective colorectal surgery to reduce the risk of SSI. (H)
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3.
Decolonize surgical patients with an anti-staphylococcal agent in the preoperative setting for orthopedic and cardiothoracic procedures. (H)
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Decolonize surgical patients in other procedures at high risk of staphylococcal SSI, such as those involving prosthetic material. (L)
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4.
Use antiseptic-containing preoperative vaginal preparation agents for patients undergoing cesarean delivery or hysterectomy. (M)
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5.
Do not remove hair at the operative site unless the presence of hair will interfere with the surgical procedure. (M)
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6.
Use alcohol-containing preoperative skin preparatory agents in combination with an antiseptic. (H)
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7.
For procedures not requiring hypothermia, maintain normothermia (temperature >35.5°C) during the perioperative period. (H)
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8.
Use impervious plastic wound protectors for gastrointestinal and biliary tract surgery. (H)
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9.
Perform intraoperative antiseptic wound lavage. (M)
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10.
Control blood-glucose level during the immediate postoperative period for all patients. (H)
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11.
Use a checklist and/or bundle to ensure compliance with best practices to improve surgical patient safety. (H)
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12.
Perform surveillance for SSI. (M)
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13.
Increase the efficiency of surveillance by utilizing automated data. (M)
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14.
Provide ongoing SSI rate feedback to surgical and perioperative personnel and leadership. (M)
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15.
Measure and provide feedback to healthcare personnel (HCP) regarding rates of compliance with process measures. (L)
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16.
Educate surgeons and perioperative personnel about SSI prevention measures. (L)
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17.
Educate patients and their families about SSI prevention as appropriate. (L)
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18.
Implement policies and practices to reduce the risk of SSI for patients that align with applicable evidence-based standards, rules and regulations, and medical device manufacturer instructions for use. (M)
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19.
Observe and review operating room personnel and the environment of care in the operating room and in central sterile reprocessing. (L)
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Additional Approaches
Can be considered for use in locations and/or hospital patient populations when HAIs are not controlled after implementation of essential practices.
1.
Perform an SSI risk assessment. (L)
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2.
Consider use of negative pressure dressings in patients who may benefit. (M)
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3.
Observe and review practices in the preoperative clinic, postanesthesia care unit, surgical intensive care unit, and/or surgical ward. (M)
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4.
Use antiseptic-impregnated sutures as a strategy to prevent SSI. (M)
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Approaches that Should Not be Considered a Routine Part of SSI Prevention
1.
Do not routinely use vancomycin for antimicrobial prophylaxis. (M)
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2.
Do not routinely delay surgery to provide parenteral nutrition. (H)
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3.
Do not routinely use antiseptic drapes as a strategy to prevent SSI. (H)
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Unresolved Issues
- Optimized tissue oxygenation at the incision site.
- Preoperative intranasal and pharyngeal chlorhexidine gluconate (CHG) treatment for patients undergoing cardiothoracic procedures.
- Use of gentamicin-collagen sponges.
- Use of antimicrobial powder.
- Use of surgical attire.
Table 2. Selected Risk Factors for and Recommendations to Prevent SSI
Intrinsic, patient-related (preoperative)
Unmodifiable
Age
No formal recommendation. Relationship to increased risk of SSI may be secondary to comorbidities or immunosenescence. ()
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History of radiation
No formal recommendation. Prior irradiation at the surgical site increases the risk of SSI, likely due to tissue damage and wound ischemia. ()
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History of skin and soft-tissue infections
No formal recommendation. History of a prior skin infection may be a marker for inherent differences in host immune function. ()
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Modifiable
Glucose control
Control serum blood-glucose levels for all surgical patients including patients without diabetes. (H)
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Obesity
Increase dosing of prophylactic antimicrobial agent for morbidly obese patients. (H)
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Smoking cessation
Encourage smoking cessation within 30 days of procedure. (H)
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Immunosuppressive medications
Avoid immune-suppressive medications in perioperative period if possible. (L)
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Hypoalbuminemia
No formal recommendation. Though a noted risk factor, do not delay surgery for use of total parenteral nutrition. ()
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S. aureus nasal colonization
Decolonize patients with nasal mupirocin or povidine-iodine prior to surgery. (M)
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Preparation of patient
Hair removal
Do not remove unless hair will interfere with the operation; if hair removal is necessary, remove outside of the operating room by clipping. Do not use razors. (H)
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Preoperative infections
Identify and treat infections remote to the surgical site (e.g., urinary tract infection prior to elective surgery). Do not routinely test or treat for asymptomatic bacteriuria except in urologic procedures. (M)
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Operative characteristics
Surgical scrub (surgical team members’ hands and forearms)
Use appropriate antiseptic agent to perform preoperative surgical scrub. For most products, scrub the hands and forearms for 2–5 minutes. (M)
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Skin preparation
Wash and clean skin around incision site. Use a dual agent skin prep containing alcohol unless contraindications exist. (H)
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Antimicrobial prophylaxis
Administer only when indicated. Select appropriate agents based on surgical procedure, most common pathogens causing SSI for a specific procedure, and published recommendations. Administer within 1 hour of incision to maximize tissue concentration. Discontinue antimicrobial agents after incisional closure in the operating room.a (H)
a Vancomycin and fluoroquinolones can be given 2 hours prior to incision.
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Blood transfusion
Blood transfusions increase the risk of SSI by decreasing macrophage function. Limit blood loss and need for blood transfusion to the greatest extent possible. (M)
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Surgeon skill/technique
Handle tissue carefully and eradicate dead space. (L)
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Appropriate gloving
All members of the operative team should double glove and change gloves when perforation is noted. (L)
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Asepsis
Adhere to standard principles of operating room asepsis. (L)
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Operative time
No formal recommendation. Minimize as much as possible without sacrificing surgical technique and aseptic practice. (H)
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Operating room characteristics
Ventilation
Follow ANSI/ASHRAE/ASHE Standard 170 recommendationsb for proper air handling in the operating room. (L)
b Guidelines—ANSI/ASHRAE/ASHE standard 170: ventilation of healthcare facilities, 2010. Facility Guidelines Institute website. http://www.fgiguidelines.org/guidelines2010.php. Published February 2, 2013. Accessed March 28, 2023.
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Traffic
Minimize operating room traffic. (L)
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Environmental surfaces
Use an Environmental Protection Agency (EPA)- approved hospital disinfectant to clean visibly soiled or contaminated surfaces and equipment in accordance with manufacturer’s instructions. (L)
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Sterilization of surgical equipment
Sterilize all surgical equipment according the device manufacturer’s validated parameters: cycle type, time, temperature, pressure, and dry time. Minimize the use of immediate use steam sterilization. (M)
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Recommendation Grading
Disclaimer
The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.
Overview
Title
Strategies to Prevent Surgical Site Infections in Acute-Care Hospitals
Authoring Organizations
Infectious Diseases Society of America
Society for Healthcare Epidemiology of America
Publication Month/Year
May 3, 2023
Last Updated Month/Year
October 9, 2024
Supplemental Implementation Tools
Document Type
Guideline
Country of Publication
US
Document Objectives
The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing their surgical-site infection (SSI) prevention efforts. This document updates the Strategies to Prevent Surgical Site Infections in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
Target Patient Population
Patients in acute care settings
Inclusion Criteria
Male, Female, Adolescent, Adult, Child, Older adult
Health Care Settings
Hospital, Operating and recovery room
Intended Users
Epidemiology infection prevention, nurse, nurse practitioner, physician, physician assistant
Scope
Management, Prevention
Keywords
surgical site infection, HAI, SSIs, HAIs
Source Citation
Calderwood, M., Anderson, D., Bratzler, D., Dellinger, E., Garcia-Houchins, S., Maragakis, L., . . . Kaye, K. (2023). Strategies to prevent surgical site infections in acute-care hospitals: 2022 Update. Infection Control & Hospital Epidemiology, 1-26. doi:10.1017/ice.2023.67
Methodology
Number of Source Documents
362
Literature Search Start Date
December 31, 2011
Literature Search End Date
July 31, 2021