1 Guidance

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

1.1 Information for patients and carers

1.1.1 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.

1.1.2 Offer patients and carers information and advice on how to care for their wound after discharge.

1.1.3 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.

1.1.4 Always inform patients after their operation if they have been given antibiotics.

1.2 Preoperative phase

Preoperative showering

1.2.1 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

1.2.2 Do not use hair removal routinely to reduce the risk of surgical site infection.

1.2.3 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

1.2.4 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

1.2.5 All staff should wear specific non-sterile theatre wear in all areas where operations are undertaken.

Staff leaving the operating area

1.2.6 Staff wearing non-sterile theatre wear should keep their movements in and out of the operating area to a minimum.

Nasal decontamination

1.2.7 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

1.2.8 Do not use mechanical bowel preparation routinely to reduce the risk of surgical site infection.

Hand jewellery, artificial nails and nail polish

1.2.9 The operating team should remove hand jewellery before operations.

1.2.10 The operating team should remove artificial nails and nail polish before operations.

Antibiotic prophylaxis

1.2.11 Give antibiotic prophylaxis[1] to patients before:

  • clean surgery involving the placement of a prosthesis or implant

  • clean-contaminated surgery

  • contaminated surgery.

1.2.12 Do not use antibiotic prophylaxis routinely for clean non-prosthetic uncomplicated surgery.

1.2.13 Use the local antibiotic formulary and always consider potential adverse effects when choosing specific antibiotics for prophylaxis.

1.2.14 Consider giving a single dose of antibiotic prophylaxis intravenously on starting anaesthesia. However, give prophylaxis earlier for operations in which a tourniquet is used.

1.2.15 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.

1.2.16 Give antibiotic treatment (in addition to prophylaxis) to patients having surgery on a dirty or infected wound.

1.2.17 Inform patients before the operation, whenever possible, if they will need antibiotic prophylaxis, and afterwards if they have been given antibiotics during their operation.

1.3 Intraoperative phase

Hand decontamination

1.3.1 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.

1.3.2 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

1.3.3 Do not use non-iodophor-impregnated incise drapes routinely for surgery as they may increase the risk of surgical site infection.

1.3.4 If an incise drape is required, use an iodophor-impregnated drape unless the patient has an iodine allergy.

Sterile gowns

1.3.5 The operating team should wear sterile gowns in the operating theatre during the operation.

Gloves

1.3.6 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

1.3.7 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.

1.3.8 If diathermy is to be used, ensure that antiseptic skin preparations are dried by evaporation and pooling of alcohol-based preparations is avoided.

Diathermy

1.3.9 Do not use diathermy for surgical incision to reduce the risk of surgical site infection.

Maintaining patient homeostasis

1.3.10 Maintain patient temperature in line with 'Inadvertent perioperative hypothermia' (see the NICE guideline on hypothermia).

1.3.11 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.

1.3.12 Maintain adequate perfusion during surgery.

1.3.13 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

1.3.14 Do not use wound irrigation to reduce the risk of surgical site infection.

1.3.15 Do not use intracavity lavage to reduce the risk of surgical site infection.

Antiseptic and antimicrobial agents before wound closure

1.3.16 Do not use intraoperative skin re-disinfection or topical cefotaxime in abdominal surgery to reduce the risk of surgical site infection.

Wound dressings

1.3.17 Cover surgical incisions with an appropriate interactive dressing at the end of the operation.

1.4 Postoperative phase

Changing dressings

1.4.1 Use an aseptic non-touch technique for changing or removing surgical wound dressings.

Postoperative cleansing

1.4.2 Use sterile saline for wound cleansing up to 48 hours after surgery.

1.4.3 Advise patients that they may shower safely 48 hours after surgery.

1.4.4 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

1.4.5 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

1.4.6 Do not use Eusol and gauze, or moist cotton gauze or mercuric antiseptic solutions to manage surgical wounds that are healing by secondary intention.

1.4.7 Use an appropriate interactive dressing to manage surgical wounds that are healing by secondary intention.

1.4.8 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

1.4.9 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

1.4.10 Do not use Eusol and gauze, or dextranomer or enzymatic treatments for debridement in the management of surgical site infection.

Specialist wound care services

The following recommendation has been taken unchanged from 'Guidance on the use of debriding agents and specialist wound care clinics for difficult to heal surgical wounds' (NICE technology appraisal 24).

1.4.11 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.

Terms used in this guideline

Debridement The excision or wide removal of all dead (necrotic) and damaged tissue that may develop in a surgical wound. There are currently a number of other accepted methods available for wound debridement, including surgery, biosurgery, sharp debridement, hydrocolloid dressings and hydrogels.

Healing by primary intention Occurs when a wound has been sutured after an operation and heals to leave a minimal, cosmetically acceptable scar.

Healing by secondary intention Occurs when a wound is deliberately left open at the end of an operation because of excessive bacterial contamination, particularly by anaerobes or when there is a risk of devitalised tissue, which leads to infection and delayed healing. It may be sutured within a few days (delayed primary closure), or much later when the wound is clean and granulating (secondary closure), or left to complete healing naturally without the intervention of suturing.

Homeostasis The maintenance of normal physiological function.

Interactive dressing Modern (post-1980) dressing materials. Designed to promote the wound healing process through the creation and maintenance of a local, warm, moist environment underneath the chosen dressing, when left in place for a period indicated through a continuous assessment process.

Perfusion Blood flow through tissues or organs. If not optimal, it can increase the risk of infectious complications (particularly surgical site infections).

Surgical site (wound) infection This occurs when pathogenic organisms multiply in a wound giving rise to local signs and symptoms, for example, heat, redness, pain and swelling, and (in more serious cases) with systemic signs of fever or a raised white blood cell count. Infection in the surgical wound may prevent healing taking place so that the wound edges separate or it may cause an abscess to form in the deeper tissues.

The definitions of surgical site infection may vary between research studies but are commonly based on those described by the Centers for Disease Control and Prevention although other valid measures have been used. For example, the ASEPSIS scoring method for postoperative wound infections and some studies which have focused only on the more serious deep and organ/space infections for which less subjective measures are available. Differences in case definitions should be taken into account when comparing reported rates of surgical site infection.

Surgical wound classification Clean: an incision in which no inflammation is encountered in a surgical procedure, without a break in sterile technique, and during which the respiratory, alimentary or genitourinary tracts are not entered.

Clean-contaminated: an incision through which the respiratory, alimentary, or genitourinary tract is entered under controlled conditions but with no contamination encountered.

Contaminated: an incision undertaken during an operation in which there is a major break in sterile technique or gross spillage from the gastrointestinal tract, or an incision in which acute, non-purulent inflammation is encountered. Open traumatic wounds that are more than 12–24 hours old also fall into this category.

Dirty or infected: an incision undertaken during an operation in which the viscera are perforated or when acute inflammation with pus is encountered (for example, emergency surgery for faecal peritonitis), and for traumatic wounds where treatment is delayed, there is faecal contamination, or devitalised tissue is present.

More information

You can also see this guideline in the NICE pathway on prevention and control of healthcare-associated infections.

To find out what NICE has said on topics related to this guideline, see our web page on surcical care.

See also the guideline committee's discussion and the evidence reviews (in the full guideline), and information about how the guideline was developed, including details of the committee.



[1] Also see recommendations 1.4.6.19, 1.4.6.20 and 1.4.6.21 in NICE's guideline on caesarean section.

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