Prevention Of Surgical Site Infection

Based on National Nosocomial Infections Surveillance (NNIS) system reports, Surgical Site Infections (SSIs), formerly called surgical wound infections, are the third most frequently reported nosocomial infection. They account for 14% to 16% of all nosocomial infections among hospitalized patients (Mangram, Horan, Pearson, Silver, & Jarvis, 1999). 

A SSI prevention technique is an action or set of actions intentionally taken to reduce the risk of an SSI. Some techniques are directed at reducing opportunities for microbial contamination of the patient’s tissues or sterile surgical instruments; others are adjunctive, such as using antimicrobial prophylaxis or avoiding unnecessary traumatic tissue dissection. Optimization of SSI prevention measures requires that a variety of patient and operation characteristics be carefully considered (Mangram, et al., 1999).

Patient characteristics possibly associated with an increased risk of an SSI include coincidental, remote site infections or colonization, diabetes, cigarette smoking, systemic steroid use, obesity, extremes of age, poor nutritional status, and preoperative transfusion of certain blood products (Mangram, et al., 1999).

The contribution of diabetes to SSI risk is controversial. More research is needed to assess the efficacy of perioperative blood glucose control as a prevention measure (Mangram, et al., 1999). Nicotine use delays primary wound healing and may in turn increase the risk of SSI. Patients who are receiving steroids or other immunosuppressive drugs preoperatively may be predisposed to developing SSI, but the data supporting this relationship are contradictory (Mangram, et al., 1999).

In some studies, severe protein-calorie malnutrition has been crudely associated with postoperative nosocomial infections, impaired wound healing dynamics, or death. Severe preoperative malnutrition should increase the risk of SSI; however, is difficult to demonstrate, the benefits of total parenteral nutrition (TPN) and total enteral alimentation (TEA) in reducing SSI risk are unproven. When a major elective operation is necessary in a severely malnourished patient, surgeons often use both pre and postoperative nutritional support. In addition, postoperative nutritional support is important for some major oncologic operations; for some major trauma victims; or in patients suffering catastrophic surgical complications that prevent eating or that trigger a hypermetabolic state (Mangram, et al., 1999).

Prolonged preoperative hospital stay is frequently thought to be a patient characteristic associated with increased SSI risk. However, the length of preoperative stay may be an indicator of severity of illness and co-morbid conditions requiring inpatient work-up and/or therapy before the operation (Mangram, et al., 1999).

Staph Aureus (S. Aureus) is a frequent SSI isolate. This pathogen is carried in the nares of 20% to 30% of healthy humans. S. Aureus is definitely associated with preoperative nares carriage of the organism in surgical patients (Mangram, et al., 1999). Mupirocin ointment is effective as a topical agent for eradicating S. aureus from the nares of colonized patients; however, the effect of mupirocin on reducing SSI risk has not yet been determined (Mangram, et al., 1999).

Perioperative transfusion of leukocyte-containing allogeneic blood components is an apparent risk factor for the development of postoperative bacterial infections, including SSI. However, more research is needed. There is currently no scientific basis for withholding necessary blood products from surgical patients as a means of SSI risk reduction (Mangram, et al., 1999).

The following are operative characteristics that may be associated with an increased risk of SSI (Mangram, et al., 1999.

Operation
Skin antisepsis
Preoperative shaving
Preoperative skin prep
Duration of operation
Antimicrobial prophylaxis
Operating room ventilation
Inadequate sterilization of instruments
Foreign material in the surgical site
Surgical drains
Surgical technique
Poor hemostasis
Failure to obliterate dead space
Tissue trauma
Duration of surgical scrub

A preoperative antiseptic shower or bath decreases skin microbial colony counts. Repeated antiseptic showers are indicated, because chlorhexidine gluconate-containing products require several applications to attain maximum antimicrobial benefit. Even though preoperative showers reduce the skin’s microbial colony counts, they have not definitively been shown to reduce SSI rates (Mangram, et al., 1999).

Preoperative shaving of the surgical site the night before an operation is associated with a significantly higher SSI risk than either the use of depilatory agents or no hair removal. The increased SSI risk has been attributed to microscopic cuts in the skin that serve as areas for bacterial multiplication. Shaving immediately before the operation compared to shaving within 24 hours preoperatively is associated with decreased SSI rates. Clipping hair immediately before an operation has also been associated with a lower risk of SSI than shaving or clipping the night before an operation. Some studies have shown that the use of depilatories is associated with a lower SSI risk than shaving or clipping. However, depilatories sometimes produce hypersensitivity reactions. Some studies have shown that preoperative hair removal by any means was associated with increased SSI rates and suggested that no hair be removed (Mangram, et al., 1999). AORN, the Centers for Disease Control and Prevention (CDC), and other regulatory agencies and organizations recommend that hair is best left at the surgical site. Hair should be removed only if it will interfere with the procedure. If hair is to be removed, hair removal should occur immediately before the procedure. Removal should be performed away from the area where the procedure will be performed. Hair should not be removed in the vicinity of the sterile field because the dispersal of loose hair has the potential to contaminate the surgical site and sterile field (Connor, 2003).

Commonly used antiseptic agents for preoperative preparation of skin are theiodophors (e.g., povidone-iodine), alcohol-containing products, and chlorhexidine gluconate. There are no studies that have adequately assessed the comparative effects of these preoperative skin antiseptics on SSI risk. Aqueous 70% to 92% alcohol solutions have germicidal activity against bacteria, fungi, and viruses, but spores can be resistant. Alcohol is readily available, inexpensive, and remains the most effective and rapid-acting skin antiseptic. However, alcohol is flammable, which is a disadvantage for use in the operating room. Chlorhexidine gluconate and iodophors have broad spectra of antimicrobial activity. In some comparisons of these two antiseptics as preoperative hand scrubs, chlorhexidine gluconate had greater reductions in skin microflora than did povidone-iodine and also had greater residual activity after a single application. Blood or serum proteins do not inactivate Chlorhexidine gluconate. Iodophors may be inactivated by blood or serum proteins, but exert a bacteriostatic effect as long as they are present on the skin (Mangram, et al., 1999).

Before the skin preparation of a patient is initiated, the skin should be free of gross contamination. Apply the antiseptic in concentric circles, beginning in the area of the proposed incision. The prepared area should be large enough to extend the incision or create new incisions or drain sites, if needed (Mangram, et al., 1999). Modified skin preparation procedures have not been shown to have any advantage over the above described procedure. Those modifications are removing or wiping off the skin preparation antiseptic agent after application; using an antiseptic-impregnated adhesive drape; merely painting the skin with an antiseptic in lieu of the skin preparation procedure described above; or using a “clean” versus a “sterile” surgical skin preparation kit (Mangram, et al., 1999). 

Members of the surgical team who have direct contact with the sterile operating field or sterile instruments or supplies perform a traditional procedure known as scrubbing immediately before donning sterile gowns and gloves. However, in October 2002, the CDC updated its hand hygiene recommendations and essentially abolished the traditional long presurgical scrub. For surgical hand antisepsis, the new guideline recommends using either an antimicrobial soap or an alcohol-based hand rub with persistent activity. Washing with regular soap is still necessary before using alcohol rub products, because alcohol rub products are not cleaning agents and don't remove surface dirt. No recommendation on the use of brushes was made (Maithias, 2003).

The benefits of selecting a brushless, alcohol-based surgical hand product may include fast and easy application, limited or decreased damage to the user's skin, improved compliance with hand antisepsis protocols, simplified application technique, and reduced material waste (i.e., water, brushes, packaging). Disadvantages may include user training needed; failure of the user to properly wash his or her hands before applying the product; and potential fire hazard (e.g., failure of the user to allow the alcohol to evaporate before he or she dons sterile gloves and gown, improper storage) (Conner, 2003).

The best antiseptic for use in the scrub should have a broad spectrum, fast-action, and have a persistent effect. Antiseptic agents commercially available in the United States for this purpose contain alcohol, chlorhexidine, iodine/iodophors, para-chloro- meta-xylenol, or triclosan. Povidone-iodine and chlorhexidine gluconate are the most common agents of choice for most U.S. surgical teams. However, a 7.5% povidone-iodine or 4% chlorhexidine gluconate compared to an alcoholic chlorhexidine (60% isopropanol and 0.5% chlorhexidine gluconate in 70% isopropanol), revealed that alcoholic chlorhexidine was found to have greater residual antimicrobial activity. No agent is ideal for every situation, and a major factor is its acceptability by operating room personnel after repeated use. No clinical trials have evaluated the impact of scrub agent choice on SSI risk (Mangram, et al., 1999). 

Other factors that influence the effectiveness of the surgical scrub are scrubbing technique, the duration of the scrub, the condition of the hands, and the techniques used for drying and gloving. Recent studies suggest that scrubbing for at least 2 minutes is as effective as the traditional 10-minute scrub in reducing hand bacterial colony counts; however, the optimum duration of scrubbing is not known (Mangram, et al., 1999). The first scrub of the day should include a thorough cleaning underneath fingernails. It is not clear that such cleaning is a necessary part of subsequent scrubs during the day. After performing the surgical scrub, hands should be kept up and away from the body (elbows in flexed position) so that water runs from the tips of the fingers toward the elbows. Sterile towels should be used for drying the hands and forearms before the donning of a sterile gown and gloves (Mangram, et al., 1999).

AORN recommends that cuticles, hands, and forearms should be free of open lesions and breaks in skin integrity. Personnel should not scrub or provide patient care with open lesions and should be assigned other duties (Peterson, 2003).

A surgical team member who wears artificial nails may have increased bacterial and fungal colonization of the hands despite performing an adequate hand scrub. The relationship between nail length and SSI risk is unknown; but long nails may be associated with tears in surgical gloves. The relationship between the wearing of nail polish or jewelry by surgical team members and SSI risk has not been adequately studied (Mangram, et al., 1999).

Surgical personnel who have active infections or are colonized with certain microorganisms have been linked to outbreaks or clusters of SSIs. Therefore, policies should address management of job-related illnesses, provision of post exposure prophylaxis after job-related exposures and, when necessary, exclusion of ill personnel from work or patient contact. While work exclusion policies should be enforceable and include a statement of authority to exclude ill personnel, they should also be designed to encourage personnel to report their illnesses and exposures and not penalize personnel with loss of wages, benefits, or job status (Mangram, et al., 1999).

Surgical antimicrobial prophylaxis (AMP) refers to a very brief infusion of an antimicrobial agent initiated just before an operation begins. AMP is not an attempt to sterilize tissues, but a critically timed adjunct used to reduce the microbial burden of intraoperative contamination to a level that cannot overwhelm host defenses. AMP does not pertain to prevention of SSI caused by postoperative contamination. AMP indications pertain to elective operations where skin incisions are closed in the operating room (Mangram, et al., 1999).

An AMP agent should be used only for operations or classes of operations in which its use has been shown to reduce SSI rates; or for those operations where incisional or organ/space SSI would be a catastrophe. The AMP agent should be safe, inexpensive, and have a bactericidal spectrum that covers the most probable intraoperative contaminants for the operation. The infusion should be timed so that the initial dose of antimicrobial agent gives a bactericidal concentration of the drug in serum and tissues by the time the skin is incised. Therapeutic levels should be maintained throughout the operation and until, at most, a few hours after the incision is closed in the operating room. When the duration of an operation is expected to exceed the time in which therapeutic levels of the AMP agent can be maintained, additional AMP agent should be infused (Mangram, et al., 1999).

The concept of “on-call” infusion of AMP is flawed because of delays in transport or schedule changes can mean that suboptimal tissue and serum levels may be present when the operation starts. Simple protocols of AMP timing and oversight responsibility should be designed to be practical and effective (Mangram, et al., 1999).

The CDC's wound classification system is widely accepted for classifying the degree of inherent microbial contamination of a surgical site. Descriptive characteristics are used to predict the degree of microbial contamination at the time of surgery. Wound classification is used as an indicator for determining prophylactic antimicrobial treatment and for reporting surgical site infections (Peterson, 2003). The following are standard wound classifications (Mangram, et al., 1999).

Class I, Clean, is an uninfected operative wound in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tract is not entered. In addition, clean wounds are primarily closed and, if necessary, drained with closed drainage (i.e., breast augmentation). Operative incisional wounds that follow nonpenetrating (blunt) trauma should be included in this category if they meet the criteria.

Class II, Clean-Contaminated, is an operative wound in which the respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination. Specifically, operations involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection or major break in technique is encountered.

Class III, Contaminated, is an open, fresh, accidental wounds. In addition, operations with major breaks in sterile technique (e.g., open cardiac massage) or gross spillage from the gastrointestinal tract, and incisions in which acute, nonpurulent inflammation is encountered are included in this category.

Class IV, Dirty-Infected, is an old traumatic wound with retained devitalized tissue and those that involve existing clinical infection or perforated viscera (example, colon resection). This definition suggests that the organisms causing postoperative infection were present in the operative field before the operation.

Operating room air may contain microbial-laden dust, lint, skin squames, or respiratory droplets. The microbial level in operating room air is directly proportional to the number of people moving about in the room. Therefore, personnel traffic during operations should be minimal. Outbreaks of A beta-hemolytic streptococci SSIs have been traced to airborne transmission of the organism from colonized operating room personnel. In these outbreaks, the strain causing the outbreak was recovered from the air in the operating room (Mangram, et al., 1999). 

Operating rooms should be maintained at positive pressure with respect to corridors and adjacent areas. Positive pressure prevents airflow from less clean areas into the operating rooms. All ventilation or air conditioning systems in hospitals, including those in operating rooms, should have two filter beds in series, with the efficiency of the first filter bed being >30% and that of the second filter bed being >90% (Mangram, et al., 1999). Conventional operating room ventilation systems produce a minimum of about 15 air changes of filtered air per hour, 20% of which must be fresh air. In rooms not engineered for horizontal laminar airflow, air should be introduced at the ceiling and exhausted near the floor (Anonymous, 2003). Laminar airflow has been suggested as an additional measure to reduce SSI risk for certain operations. Laminar airflow is designed to move “ultraclean air” over the aseptic operating field at a uniform velocity, sweeping away particles in its path. Laminar airflow can be directed vertically or horizontally, and recirculated air is usually passed through a high efficiency particulate air (HEPA) filter (Mangram, et al., 1999). Do not use UV radiation to prevent SSI (Anonymous, 2003).

The temperature of an operating room should be between 68-73ºF, and have a relative humidity 30%-60% (Mangram, et al., 1999). Do not use tacky mats at entrance to the ORs (Anonymous, 2003).

Surgical team members should wear a “scrub suit” that consists of pants and a shirt. Policies for laundering, wearing, covering, and changing scrub suits vary greatly. Some policies restrict the laundering of scrub suits to the facility, while other facilities have policies that allow laundering by employees. The Association of Operating Room Nurses recommends that scrub suits be changed after they become visibly soiled and that they be laundered only in an approved and monitored laundry facility. Additionally, OSHA regulations require that garment penetrated by blood or other potentially infectious materials should be removed immediately or as soon as feasible. There are no well-controlled studies evaluating scrub suit laundering as an SSI risk factor. Some facilities have policies that restrict the wearing of scrub suits to the operating suite, while other facilities allow the wearing of cover gowns over scrub suits when personnel leave the suite (Mangram, et al., 1999).

Wearing a surgical mask during an operation to prevent potential microbial contamination of incisions is a longstanding surgical tradition. A mask can be beneficial since it protects the wearer’s nose and mouth from inadvertent splashes of blood and other body fluids. OSHA regulations require that masks in combination with protective eyewear, such as goggles or glasses with solid shields, or chin-length face shields be worn whenever splashes, spray, spatter, or droplets of blood or other potentially infectious material may be generated and eye, nose, or mouth contamination can be reasonably anticipated. However, some studies have raised questions about the efficacy and cost-benefit of surgical masks in reducing SSI risk (Mangram, et al., 1999).

Surgical caps/hoods are inexpensive and reduce contamination of the surgical field by organisms shed from the hair and scalp. SSI outbreaks have occasionally been traced to organisms isolated from the hair or scalp, even when personnel wore caps. The use of shoe covers has never been shown to decrease SSI risk or to decrease bacteria counts on the operating room floor. Shoe covers may, however, protect surgical team members from exposure to blood and other body fluids during an operation. OSHA regulations require that surgical caps or hoods and shoe covers or boots be worn in situations when gross contamination can reasonably be anticipated (Mangram, et al., 1999).

Sterile gloves are put on after donning sterile gowns. A strong theoretical rationale supports the wearing of sterile gloves by all scrubbed members of the surgical team. Sterile gloves are worn to minimize transmission of microorganisms from the hands of team members to patients and to prevent contamination of team members’ hands with patients’ blood and body fluids. If the integrity of a glove is compromised it should be changed as promptly as safety permits. Wearing two pairs of gloves, double-gloving, has been shown to reduce hand contact with patients’ blood and body fluids when compared to wearing only a single pair (Mangram, et al., 1999).

Sterile surgical gowns and drapes are used to create a barrier between the surgical field and potential sources of bacteria. All scrubbed surgical team members wear gowns and drapes are placed over the patient. There are limited data that can be used to understand the relationship of gown or drape characteristics with SSI risk. The wide variation in the products and study designs make interpretation of the literature difficult (Mangram, et al., 1999).

Gowns and drapes are classified as disposable or reusable. Regardless of the material used to manufacture gowns and drapes, these items should be impermeable to liquids and viruses. Only gowns reinforced with films, coatings, or membranes meet standards developed by the American Society for Testing and Materials. However, such “liquid-proof” gowns may be uncomfortable because they also inhibit heat loss and the evaporation of sweat from the wearer’s body. These factors should be considered when selecting gowns (Mangram, et al., 1999).

AORN makes no official recommendation about the length of the drape that extends over the edge of the sterile back table. The draped table is sterile only at the top surface and drapes extending below the table level are considered unsterile. The length of the drape extending over the edge of a draped surface becomes irrelevant in terms of sterility because any portion of the drape beyond the flat surface is contaminated. After a drape is placed, it should not be shifted or moved so that part of the drape that was below the table level is not moved inadvertently to the top, because this compromises the sterile field (Peterson, 2003).Operating room air may contain microbial-laden dust, lint, skin squames, or respiratory droplets. The microbial level in operating room air is directly proportional to the number of people moving about in the room. Therefore, personnel traffic during operations should be minimal. Outbreaks of A beta-hemolytic streptococci SSIs have been traced to airborne transmission of the organism from colonized operating room personnel. In these outbreaks, the strain causing the outbreak was recovered from the air in the operating room (Mangram, et al., 1999). 

Operating rooms should be maintained at positive pressure with respect to corridors and adjacent areas. Positive pressure prevents airflow from less clean areas into the operating rooms. All ventilation or air conditioning systems in hospitals, including those in operating rooms, should have two filter beds in series, with the efficiency of the first filter bed being >30% and that of the second filter bed being >90% (Mangram, et al., 1999). Conventional operating room ventilation systems produce a minimum of about 15 air changes of filtered air per hour, 20% of which must be fresh air. In rooms not engineered for horizontal laminar airflow, air should be introduced at the ceiling and exhausted near the floor (Anonymous, 2003). Laminar airflow has been suggested as an additional measure to reduce SSI risk for certain operations. Laminar airflow is designed to move “ultraclean air” over the aseptic operating field at a uniform velocity, sweeping away particles in its path. Laminar airflow can be directed vertically or horizontally, and recirculated air is usually passed through a high efficiency particulate air (HEPA) filter (Mangram, et al., 1999). Do not use UV radiation to prevent SSI (Anonymous, 2003).

The temperature of an operating room should be between 68-73ºF, and have a relative humidity 30%-60% (Mangram, et al., 1999). Do not use tacky mats at entrance to the ORs (Anonymous, 2003).

Surgical team members should wear a “scrub suit” that consists of pants and a shirt. Policies for laundering, wearing, covering, and changing scrub suits vary greatly. Some policies restrict the laundering of scrub suits to the facility, while other facilities have policies that allow laundering by employees. The Association of Operating Room Nurses recommends that scrub suits be changed after they become visibly soiled and that they be laundered only in an approved and monitored laundry facility. Additionally, OSHA regulations require that garment penetrated by blood or other potentially infectious materials should be removed immediately or as soon as feasible. There are no well-controlled studies evaluating scrub suit laundering as an SSI risk factor. Some facilities have policies that restrict the wearing of scrub suits to the operating suite, while other facilities allow the wearing of cover gowns over scrub suits when personnel leave the suite (Mangram, et al., 1999).

Wearing a surgical mask during an operation to prevent potential microbial contamination of incisions is a longstanding surgical tradition. A mask can be beneficial since it protects the wearer’s nose and mouth from inadvertent splashes of blood and other body fluids. OSHA regulations require that masks in combination with protective eyewear, such as goggles or glasses with solid shields, or chin-length face shields be worn whenever splashes, spray, spatter, or droplets of blood or other potentially infectious material may be generated and eye, nose, or mouth contamination can be reasonably anticipated. However, some studies have raised questions about the efficacy and cost-benefit of surgical masks in reducing SSI risk (Mangram, et al., 1999).

Surgical caps/hoods are inexpensive and reduce contamination of the surgical field by organisms shed from the hair and scalp. SSI outbreaks have occasionally been traced to organisms isolated from the hair or scalp, even when personnel wore caps. The use of shoe covers has never been shown to decrease SSI risk or to decrease bacteria counts on the operating room floor. Shoe covers may, however, protect surgical team members from exposure to blood and other body fluids during an operation. OSHA regulations require that surgical caps or hoods and shoe covers or boots be worn in situations when gross contamination can reasonably be anticipated (Mangram, et al., 1999).

Sterile gloves are put on after donning sterile gowns. A strong theoretical rationale supports the wearing of sterile gloves by all scrubbed members of the surgical team. Sterile gloves are worn to minimize transmission of microorganisms from the hands of team members to patients and to prevent contamination of team members’ hands with patients’ blood and body fluids. If the integrity of a glove is compromised it should be changed as promptly as safety permits. Wearing two pairs of gloves, double-gloving, has been shown to reduce hand contact with patients’ blood and body fluids when compared to wearing only a single pair (Mangram, et al., 1999).

Sterile surgical gowns and drapes are used to create a barrier between the surgical field and potential sources of bacteria. All scrubbed surgical team members wear gowns and drapes are placed over the patient. There are limited data that can be used to understand the relationship of gown or drape characteristics with SSI risk. The wide variation in the products and study designs make interpretation of the literature difficult (Mangram, et al., 1999).

Gowns and drapes are classified as disposable or reusable. Regardless of the material used to manufacture gowns and drapes, these items should be impermeable to liquids and viruses. Only gowns reinforced with films, coatings, or membranes meet standards developed by the American Society for Testing and Materials. However, such “liquid-proof” gowns may be uncomfortable because they also inhibit heat loss and the evaporation of sweat from the wearer’s body. These factors should be considered when selecting gowns (Mangram, et al., 1999).

AORN makes no official recommendation about the length of the drape that extends over the edge of the sterile back table. The draped table is sterile only at the top surface and drapes extending below the table level are considered unsterile. The length of the drape extending over the edge of a draped surface becomes irrelevant in terms of sterility because any portion of the drape beyond the flat surface is contaminated. After a drape is placed, it should not be shifted or moved so that part of the drape that was below the table level is not moved inadvertently to the top, because this compromises the sterile field (Peterson, 2003).

Rigorous adherence to the principles of asepsis by all scrubbed personnel is the foundation of surgical site infection prevention. Others who work in close proximity to the sterile surgical field, such as anesthesia personnel, must also abide by these principles. SSIs have occurred in which anesthesia personnel were implicated as the source of the pathogen. Anesthesiologists and nurse anesthetists perform a variety of invasive procedures such as placement of intravascular devices and endotracheal tubes, and administration of intravenous drugs and solutions. Lack of adherence to the principles of asepsis during such procedures, including use of contaminated syringes and contaminated infusion pumps, and the assembly of equipment and solutions in advance of procedures, have been associated with outbreaks of postoperative infections, including SSI (Mangram, et al., 1999).

The type of postoperative incision care is determined by whether the incision is closed primarily, left open to be closed later, or left open to heal by second intention. When a surgical incision is closed primarily, as most are, the incision is usually covered with a sterile dressing for 24 to 48 hours. Beyond 48 hours, it is unclear whether a dressing must cover an incision or whether showering or bathing is detrimental to healing. When a surgical incision is left open at the skin level for a few days before it is closed, delayed primary closure, a surgeon has determined that it is likely to be contaminated or that the patient’s condition prevents primary closure. When such is the case, the incision is packed with a sterile dressing. When a surgical incision is left open to heal by second intention, it is also packed with sterile moist gauze and covered with a sterile dressing. The American College of Surgeons, CDC, and others have recommended using sterile gloves and equipment (sterile technique) when changing dressings on any type of surgical incision (Mangram, et al., 1999).

The Guideline for Prevention of Surgical Site Infection, 1999, provides recommendations concerning reduction of surgical site infection risk. Each recommendation is categorized on the basis of existing scientific data, theoretical rationale, and applicability. 

Category I recommendations, including IA and IB, are those recommendations that are viewed as effective by the Hospital Infection Control Practices Advisory Committee of the National Center for Infectious Diseases and experts in the fields of surgery, infectious diseases, and infection control. Both Category IA and IB recommendations are applicable for, and should be adopted by, all healthcare facilities; IA and IB recommendations differ only in the strength of the supporting scientific evidence.

Category II recommendations are supported by less scientific data than Category I recommendations; such recommendations may be appropriate for addressing specific nosocomial problems or specific patient populations. No recommendation is offered for some practices, either because there is a lack of consensus regarding their efficacy or because the available scientific evidence is insufficient to support their adoption. For such unresolved issues, practitioners should use judgment to determine a policy regarding these practices within their organization.

Category IA. Strongly recommended for implementation and supported by well-designed experimental, clinical, or epidemiological studies.

Category IB. Strongly recommended for implementation and supported by some experimental, clinical, or epidemiological studies and strong theoretical rationale.

Category II. Suggested for implementation and supported by suggestive clinical or epidemiological studies or theoretical rationale.

No recommendation; unresolved issue. Practices for which insufficient evidence or no consensus regarding efficacy exists.

Practices required by federal regulation are denoted with an asterisk (*).
 

Preparation of the patient

1. Whenever possible, identify and treat all infections remote to the surgical site before elective operation and postpone elective operations on patients with remote site infections until the infection has resolved. Category IA

2. Do not remove hair preoperatively unless the hair at or around the incision site will interfere with the operation. Category IA

3. If hair is removed, remove immediately before the operation, preferably with electric clippers. Category IA

4. Adequately control serum blood glucose levels in all diabetic patients and particularly avoid hyperglycemia perioperatively. Category IB

5. Encourage tobacco cessation. At minimum, instruct patients to abstain for at least 30 days before elective operation from smoking cigarettes, cigars, pipes, or any other form of tobacco consumption (e.g., chewing/dipping). Category IB

6. Do not withhold necessary blood products from surgical patients as a means to prevent SSI. Category IB

7. Require patients to shower or bathe with an antiseptic agent on at least the night before the operative day. Category IB

8. Thoroughly wash and clean at and around the incision site to remove gross contamination before performing antiseptic skin preparation. Category IB

9. Use an appropriate antiseptic agent for skin preparation. Category IB

10. Apply preoperative antiseptic skin preparation in concentric circles moving toward the periphery. The prepared area must be large enough to extend the incision or create new incisions or drain sites, if necessary. Category II

11. Keep preoperative hospital stay as short as possible while allowing for adequate preoperative preparation of the patient. Category II

12. No recommendation to taper or discontinue systemic steroid use (when medically permissible) before elective operation. Unresolved issue

13. No recommendation to enhance nutritional support for surgical patients solely as a means to prevent SSI. Unresolved issue

14. No recommendation to preoperatively apply mupirocin to nares to prevent SSI. Unresolved issue

15. No recommendation to provide measures that enhance wound space oxygenation to prevent SSI. Unresolved issue

Hand/forearm antisepsis for surgical team members 

1. Keep nails short and do not wear artificial nails. Category IB

2. Perform a preoperative surgical scrub for at least 2 to 5 minutes using an appropriate antiseptic. Scrub the hands and forearms up to the elbows. Category IB. However, in October 2002, the CDC updated its hand hygiene recommendations and essentially abolished the traditional long presurgical scrub. For surgical hand antisepsis, the new guideline recommends using either an antimicrobial soap or an alcohol-based hand rub with persistent activity. Washing with regular soap is still necessary before using alcohol rub products, because alcohol rub products are not cleaning agents and don't remove surface dirt. No recommendation on the use of brushes was made (Maithias, 2003).

3. After performing the surgical scrub, keep hands up and away from the body (elbows in flexed position) so that water runs from the tips of the fingers toward the elbows. Dry hands with a sterile towel and don a sterile gown and gloves. Category IB

4. Clean underneath each fingernail prior to performing the first surgical scrub of the day. Category II

5. Do not wear hand or arm jewelry. Category II

6. No recommendation on wearing nail polish. Unresolved Issue

Management of infected or colonized surgical personnel

1. Educate and encourage surgical personnel who have signs and symptoms of a transmissible infectious illness to report conditions promptly to their supervisory and occupational health service personnel. Category IB

2. Develop well-defined policies concerning patient-care responsibilities when personnel have potentially transmissible infectious conditions. These policies should govern (a) personnel responsibility in using the health service and reporting illness, (b) work restrictions, and (c) clearance to resume work after an illness that required work restriction. The policies also should identify persons who have the authority to remove personnel from duty. Category IB

3. Obtain appropriate cultures from, and exclude from duty, surgical personnel who have draining skin lesions until infection has been ruled out or personnel have received adequate therapy and infection has resolved. Category IB

4. Do not routinely exclude surgical personnel who are colonized with organisms such as S. aureus (nose, hands, or other body site) or group A Streptococcus, unless such personnel have been linked epidemiologically to dissemination of the organism in the healthcare setting. Category IB

Ventilation (Anonymous, 2003)

1. Maintain positive-pressure ventilation in the operating room with respect to the corridors and adjacent areas. Category IB

2. Maintain a minimum of 15 air changes per hour, of which at least 3 should be fresh air. Category IB

3. Filter all air, recirculated and fresh, through the appropriate filters per the American Institute of Architects’ recommendations. Category IB

4. Introduce all air at the ceiling, and exhaust near the floor. Category IB

5. Do not use UV radiation in the operating room to prevent SSI. Category IB

6. Keep operating room doors closed except as needed for passage of equipment, personnel, and the patient. Category IB

7. Consider performing orthopedic implant operations in operating rooms supplied with ultraclean air. Category II

8. Limit the number of personnel entering the operating room to necessary personnel. Category II

Cleaning and disinfection of environmental surfaces

1. When visible soiling or contamination with blood or other body fluids of surfaces or equipment occurs during an operation, use an EPA-approved hospital disinfectant to clean the affected areas before the next operation. Category IB*

2. Do not perform special cleaning or closing of operating rooms after contaminated or dirty operations. Category IB

3. Do not use tacky mats at the entrance to the operating room suite or individual operating rooms for infection control. Category IB

4. Wet vacuum the operating room floor after the last operation of the day or night with an EPA-approved hospital disinfectant. Category II

5. No recommendation on disinfecting environmental surfaces or equipment used in operating rooms between operations in the absence of visible soiling. Unresolved issue

6. After the last surgical procedure of the day or night, wet vacuum or mop OR floors with a single-use mop and an EPA-registered hospital disinfectant. IB (Anonymous, 2003).

Microbiologic sampling

1. Do not perform routine environmental sampling of the operating room. Perform microbiologic sampling of operating room environmental surfaces or air only as part of an epidemiologic investigation. Category IB

Sterilization of surgical instruments

1. Sterilize all surgical instruments according to published guidelines. Category IB

2. Perform flash sterilization only for patient care items that will be used immediately (e.g., to reprocess an inadvertently dropped instrument). Do not use flash sterilization for reasons of convenience, as an alternative to purchasing additional instrument sets, or to save time. Category IB

Recommendations: Water Automatic endoscope reprocessors (Anonymous, 2003).

1. Clean, disinfect, and maintain automatic endoscope reprocessor (AER) equipment according to the manufacturer's instructions and relevant scientific literature to prevent inadvertent contamination of endoscopes and bronchoscopes with waterborne microorganisms. IB

2. To rinse disinfected endoscopes and bronchoscopes, use water of the highest quality practical for the system's engineering and design (e.g., sterile water or bacteriologically filtered water [water filtered through 0.1 to 0.2 [mu]m filters]). IB

3. Dry internal channels of the reprocessed endoscope or bronchoscope using a proven method (e.g., 70% alcohol followed by forced-air treatment) to lessen potential for proliferation of waterborne microorganisms and to help prevent biofilm formation. IB

Surgical attire and drapes

1. Wear a surgical mask that fully covers the mouth and nose when entering the operating room if an operation is about to begin or already under way, or if sterile instruments are exposed. Wear the mask throughout the operation. Category IB*

2. Wear a cap or hood to fully cover hair on the head and face when entering the operating room. Category IB*

3. Do not wear shoe covers for the prevention of SSI. Category IB*

4. Wear sterile gloves if a scrubbed surgical team member. Put on gloves after donning a sterile gown. Category IB*

5. Use surgical gowns and drapes that are effective barriers when wet (i.e., materials that resist liquid penetration). Category IB

6. Change scrub suits that are visibly soiled, contaminated, and/or penetrated by blood or other potentially infectious materials. Category IB*

7. Employers must launder workers' personal protective garments or uniforms contaminated with blood or other potentially infectious materials (Anonymous, 2003). No recommendations on how or where to launder scrub suits, on restricting use of scrub suits to the operating suite, or for covering scrub suits when out of the operating suite. Unresolved issue *

8. Use sterilized textiles, surgical drapes, and gowns for situations requiring sterility. IB (Anonymous, 2003)

9. No recommendation regarding using disposable fabrics versus durable goods. Unresolved issue (Anonymous, 2003).

Asepsis and surgical technique

1. Adhere to principles of asepsis when placing intravascular devices (e.g., central venous catheters), spinal or epidural anesthesia catheters, or when dispensing and administering intravenous drugs. Category IA

2. Assemble sterile equipment and solutions immediately prior to use. Category II

3. Handle tissue gently, maintain effective hemostasis, minimize devitalized tissue and foreign bodies (i.e., sutures, charred tissues, necrotic debris), and eradicate dead space at the surgical site. Category IB

4. Use delayed primary skin closure or leave an incision open to heal by second intention if the surgeon considers the surgical site to be heavily contaminated (e.g., Class III and Class IV). Category IB

5. If drainage is necessary, use a closed suction drain. Place a drain through a separate incision distant from the operative incision. Remove the drain as soon as possible. Category IB

1. Protect with a sterile dressing for 24 to 48 hours postoperatively an incision that has been closed primarily. Category IB

2. Wash hands before and after dressing changes and any contact with the surgical site. Category IB

3. When an incision dressing must be changed, use sterile technique. Category II

4. Educate the patient and family regarding proper incision care, symptoms of SSI, and the need to report such symptoms. Category II

5. No recommendation to cover an incision closed primarily beyond 48 hours, nor on the appropriate time to shower or bathe with an uncovered incision. Unresolved issue

Anonymous. (2003). CDC issues new environmental guidelines. OR Manager. 19(8), 20. Retrieved 1/4/04 from ProQuest.

Conner, R. (2003). Fire blankets, alcohol-based hand scrubs, peel pouch indicators, aseptic technique definitions, shaving. AORN Journal. 78(3), 483. Retrieved 1/4/04 from ProQuest.

Mangram, A., Horan, T., Pearson M., Silver, L., and Jarvis W. (1999). Guidelines for prevention of surgical site infection. Infection Control and Hospital Epidemiology, 20(4), 247 Retrieved 1/4/04 from http://www.cdc.gov/ncidod/hip/SSI/SSI_guideline.htm.

Maithias, J. (2003). New alcohol-based hand rubs catch on quickly with staff, MDs. OR Manager, 19(1), 1-3. Retrieved 1/4/04 from ProQuest.

Peterson, C. (2003). Clinical issues: Table overhang, hypothermia, separating sponges, skin lacerations when scrubbing, wound classification, forced air warming. AORN Journal, 78(1), 123. Retrieved 1/4/04 from ProQuest.