Strategies to Prevent Surgical Site Infections in Acute Care Hospitals

Publication Date: May 4, 2023

Key Points

Key Points

  • In the preoperative setting, decolonize surgical patients with an anti-staphylococcal agent for cardiothoracic and orthopedic procedures.
    • Consider decolonization for patients undergoing other procedures at high risk of staphylococcal surgical site infection (SSI), such as those involving prosthetic material.
  • After a patient’s incision is closed, immediately discontinue antibiotics that were administered before and during surgery.
    • No evidence supports continuing antibiotics after a patient’s incision has been closed prevents surgical site infections, even if the incision has drains.
    • Continuing antibiotics increases the patient’s risk of C. difficile infection, acute kidney injury, and antimicrobial resistance.
  • For patients undergoing elective surgery involving the colon, administer oral antibiotics in addition to parenteral (IV) antibiotics, rather than performing mechanical bowel preparation without oral antibiotics.
    • Patients who get mechanical bowel preparation without oral antimicrobial agents have more complications.
  • For patients undergoing cesarean delivery or hysterectomy, use antiseptic-containing preoperative vaginal preparation agents to reduce the risk of endometritis.
  • Obtain a full allergy history.
    • 10% of the population reports a penicillin allergy, but <1% of the population is truly allergic (CDC). Many patients with a self-reported penicillin allergy can safely receive the antibiotic as prophylaxis.
    • Understand the nature of the patient’s listed allergy to avoid unnecessary use of less effective antibiotics to prevent SSIs.
  • Do not routinely use vancomycin for antimicrobial prophylaxis.
    • Reserve vancomycin for specific clinical situations (e.g., if a patient is known to be colonized with methicillin-resistant Staphylococcus aureus (MRSA), and especially if the patient’s surgery involves prosthetic material and/or will occur in the setting of an outbreak due to MRSA).
  • For skin preparation prior to surgical incision, data from recent trials favor CHG-alcohol over povidone-iodine-alcohol.
  • Perform antiseptic wound lavage intraoperatively. Ensure the sterility of the antiseptic used.
    • Evidence does not support the use of saline lavage (non-antiseptic lavage).
    • The authors recommend dilute povidone-iodine lavage rather than antibiotic irrigation.
  • The use of supplemental oxygen for patients requiring mechanical ventilation is now an unresolved issue and no longer an essential practice.
  • As an additional approach, consider the use of antiseptic-impregnated sutures at wound closure, particularly in colorectal surgery cases.
  • In the OR and the post-acute care unit, during patients’ postoperative days 1-2 monitor and maintain blood glucose levels between 110-150 mg/dL in patients who are hyperglycemic, regardless of diabetes status.
    • Postoperative blood glucose control that targets levels <110 mg/dL has been associated with a risk of significantly lowering the blood glucose level and increasing the risk of stroke or death.
  • As an additional approach, consider the use of negative pressure dressings in the postoperative setting.
    • The authors added negative pressure dressings as an additional approach, as some studies support their use in patients who have undergone abdominal surgery or joint arthroplasty.
    • Evidence suggests that the benefit increases with age and body mass index.
  • This pocket guide highlights practical recommendations to assist acute care hospitals in implementing and prioritizing SSI prevention efforts.
  • It is based on a synthesis of evidence, theoretical rationale, current practices, practical considerations, author consensus, and consideration of potential harm, where applicable.
  • No guideline or expert guidance document can anticipate all clinical situations. This pocket guide is not meant to be a substitute for individual clinical judgment by qualified professionals.

Recommendations

Recommenda...

...commendations to Prevent Surgical Site Infe...

...ssential Practices...

...d by all acute-care hospitals unless a clear and...

...antimicrobial prophylaxis according to...

...ation of parenteral and oral antimicrob...

3.

...ize surgical patients with an anti-staphylococca...

...gical patients in other procedures at high ri...

...antiseptic-containing preoperative vaginal pr...

...t remove hair at the operative site unl...

...ontaining preoperative skin preparatory agents in...

...not requiring hypothermia, maintain normot...

...pervious plastic wound protectors for gastroint...

...Perform intraoperative antiseptic wound lavage. (...

...ood-glucose level during the immediate postop...

...cklist and/or bundle to ensure complianc...

...orm surveillance for SSI. (M)3305...

...rease the efficiency of surveillance by ut...

...ngoing SSI rate feedback to surgical and perioper...

...e and provide feedback to healthcare p...

...6.Educate surgeons and perioperati...

....Educate patients and their families abo...

...licies and practices to reduce the r...

...serve and review operating room personnel...

...itional Approache...

Can be considered for use in locations an...

...erform an SSI risk assessment. (L)3305355

...sider use of negative pressure dressings...

...bserve and review practices in the preopera...

...tic-impregnated sutures as a strategy to...

...pproaches that Should Not be Considered a...

...ot routinely use vancomycin for antimicrobial pro...

...routinely delay surgery to provide parent...

...nely use antiseptic drapes as a strategy to p...

Unresolved Issues...


...d Risk Factors for and Recommendati...

...patient-related (preoperative)...

Unmodifi...

AgeNo formal recommendation. Relationship...

...radiationNo formal recommendation. Prior irradi...

...tory of skin and soft-tissue infections...

...odifiable...

...cose controlControl serum blood-gl...

...tyIncrease dosing of prophylactic antimicrobi...

...nEncourage smoking cessation within 30 day...

...suppressive medicationsAvoid immune-su...

...iaNo formal recommendation. Though a noted risk...

...us nasal colonizationDecolonize patients wi...

...ration of patien...

...movalDo not remove unless hair wil...

...erative infectionsIdentify and treat infect...

...ive characteristics...

Surgical scrub (surgical team members’ han...

...tionWash and clean skin around incision site. Use...

...prophylaxisAdminister only when indicated. Selec...

...transfusionBlood transfusions incre...

...ll/techniqueHandle tissue carefully...

Appropriate glovingAll members of the operat...

...sisAdhere to standard principles of operating...

...o formal recommendation. Minimize as much as p...

...rating room characteristic...

...ilationFollow ANSI/ASHRAE/ASHE Standard 1...

...ze operating room traffic. (L)3305355...

...nmental surfacesUse an Environmental Protection A...

...f surgical equipmentSterilize all sur...


...1. Centers for Disease Control and Prevention...


Table 3. SSI Prevention Internal Reporting Pro...

...orting Process Measure Example: Compl...

...rting Outcome Measure Example: Surgical Site Infec...


Table 4. SSI Prevention External Reporting Outcome...

...rementsa Reported via CDC NHSN in the...

...ements and Collaboratives In sta...


...ental Elements of Accountability an...