Information for Patients and Carers
Offer patients and carers clear, consistent information and advice throughout all stages of their care. This should include the risks of surgical site infections, what is being done to reduce them and how they are managed.
Offer patients and carers information and advice on how to care for their wound after discharge.
Offer patients and carers information and advice about how to recognise a surgical site infection and who to contact if they are concerned. Use an integrated care pathway for healthcare-associated infections to help communicate this information to both patients and all those involved in their care after discharge.
Always inform patients after their operation if they have been given antibiotics.
Preoperative Phase
Preoperative Showering
Advise patients to shower or have a bath (or help patients to shower, bath or bed bath) using soap, either the day before, or on the day of, surgery.
Hair Removal
Do not use hair removal routinely to reduce the risk of surgical site infection.
If hair has to be removed, use electric clippers with a single-use head on the day of surgery. Do not use razors for hair removal, because they increase the risk of surgical site infection.
Patient Theatre Wear
Give patients specific theatre wear that is appropriate for the procedure and clinical setting and that provides easy access to the operative site and areas for placing devices, such as intravenous cannulas. Consider also the patient's comfort and dignity.
Staff Theatre Wear
All staff should wear specific non-sterile theatre wear in all areas where operations are undertaken.
Staff Leaving the Operating Area
Staff wearing non-sterile theatre wear should keep their movements in and out of the operating area to a minimum.
Nasal Decontamination
Do not use nasal decontamination with topical antimicrobial agents aimed at eliminating Staphylococcus aureus routinely to reduce the risk of surgical site infection.
Mechanical Bowel Preparation
Do not use mechanical bowel preparation routinely to reduce the risk of surgical site infection.
Hand Jewelry, Artificial Nails, and Nail Polish
The operating team should remove hand jewelry before operations.
The operating team should remove artificial nails and nail polish before operations.
Antibiotic Prophylaxis
Give antibiotic prophylaxis to patients before:
- Clean surgery involving the placement of a prosthesis or implant
- Clean-contaminated surgery
- Contaminated surgery
Do not use antibiotic prophylaxis routinely for clean non-prosthetic uncomplicated surgery.
Use the local antibiotic formulary and always consider potential adverse effects when choosing specific antibiotics for prophylaxis.
Consider giving a single dose of antibiotic prophylaxis intravenously on starting anaesthesia. However, give prophylaxis earlier for operations in which a tourniquet is used.
Before giving antibiotic prophylaxis, consider the timing and pharmacokinetics (for example, the serum half-life) and necessary infusion time of the antibiotic. Give a repeat dose of antibiotic prophylaxis when the operation is longer than the half-life of the antibiotic given.
Give antibiotic treatment (in addition to prophylaxis) to patients having surgery on a dirty or infected wound.
Inform patients before the operation, whenever possible, if they will need antibiotic prophylaxis, and afterwards if they have been given antibiotics during their operation.
Intraoperative Phase
Hand Decontamination
The operating team should wash their hands prior to the first operation on the list using an aqueous antiseptic surgical solution, with a single-use brush or pick for the nails, and ensure that hands and nails are visibly clean.
Before subsequent operations, hands should be washed using either an alcoholic hand rub or an antiseptic surgical solution. If hands are soiled then they should be washed again with an antiseptic surgical solution.
Incise Drapes
Do not use non-iodophor-impregnated incise drapes routinely for surgery as they may increase the risk of surgical site infection.
If an incise drape is required, use an iodophor-impregnated drape unless the patient has an iodine allergy.
Use of Sterile Gowns
The operating team should wear sterile gowns in the operating theatre during the operation.
Gloves
Consider wearing two pairs of sterile gloves when there is a high risk of glove perforation and the consequences of contamination may be serious.
Antiseptic Skin Preparation
Prepare the skin at the surgical site immediately before incision using an antiseptic (aqueous or alcohol-based) preparation: povidone-iodine or chlorhexidine are most suitable.
If diathermy is to be used, ensure that antiseptic skin preparations are dried by evaporation and pooling of alcohol-based preparations is avoided.
Diathermy
Do not use diathermy for surgical incision to reduce the risk of surgical site infection.
Maintaining Patient Homeostasis
Maintain patient temperature in line with 'Inadvertent perioperative hypothermia' (NICE clinical guideline 65).
Maintain optimal oxygenation during surgery. In particular, give patients sufficient oxygen during major surgery and in the recovery period to ensure that a haemoglobin saturation of more than 95% is maintained.
Maintain adequate perfusion during surgery.
Do not give insulin routinely to patients who do not have diabetes to optimise blood glucose postoperatively as a means of reducing the risk of surgical site infection.
Wound Irrigation and Intracavity Lavage
Do not use wound irrigation to reduce the risk of surgical site infection.
Do not use intracavity lavage to reduce the risk of surgical site infection.
Antiseptic and Antimicrobial Agents before Wound Closure
Do not use intraoperative skin re-disinfection or topical cefotaxime in abdominal surgery to reduce the risk of surgical site infection.
Wound Dressings
Cover surgical incisions with an appropriate interactive dressing at the end of the operation.
Postoperative Phase
Changing Dressings
Use an aseptic non-touch technique for changing or removing surgical wound dressings.
Postoperative Cleansing
Use sterile saline for wound cleansing up to 48 hours after surgery.
Advise patients that they may shower safely 48 hours after surgery.
Use tap water for wound cleansing after 48 hours if the surgical wound has separated or has been surgically opened to drain pus.
Topical Antimicrobial Agents for Wound Healing by Primary Intention
Do not use topical antimicrobial agents for surgical wounds that are healing by primary intention to reduce the risk of surgical site infection.
Dressings for Wound Healing by Secondary Intention
Do not use Eusol and gauze, or moist cotton gauze or mercuric antiseptic solutions to manage surgical wounds that are healing by secondary intention.
Use an appropriate interactive dressing to manage surgical wounds that are healing by secondary intention.
Refer to a tissue viability nurse (or another healthcare professional with tissue viability expertise) for advice on appropriate dressings for the management of surgical wounds that are healing by secondary intention.
Antibiotic Treatment of Surgical Site Infection and Treatment Failure
When surgical site infection is suspected (i.e., cellulitis), either de novo or because of treatment failure, give the patient an antibiotic that covers the likely causative organisms. Consider local resistance patterns and the results of microbiological tests in choosing an antibiotic.
Debridement
Do not use Eusol and gauze, or dextranomer or enzymatic treatments for debridement in the management of surgical site infection.
Specialist Wound Care Services
Although there is no direct evidence to support the provision of specialist wound care services for managing difficult to heal surgical wounds, a structured approach to care (including preoperative assessments to identify individuals with potential wound healing problems) is required in order to improve overall management of surgical wounds. To support this, enhanced education of healthcare workers, patients and carers, and sharing of clinical expertise will be required.
