Wound Infection Guidelines

Updated: Jun 11, 2018
  • Author: Hemant Singhal, MD, MBBS, MBA, FRCS, FRCS(Edin), FRCSC; Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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CDC Guidelines for Prevention of Surgical Site Infection

In 2017, the Centers for Disease Control and Prevention (CDC) published an updated guideline for the prevention of surgical site infections (SSIs), [23]  which included the following recommendations:

  • Administer preoperative antimicrobial agents only when indicated by published clinical practice guidelines, and time administration so that a bactericidal concentration is established in serum and tissues when the incision is made (strong recommendation; accepted practice).
  • Administer appropriate parenteral prophylactic antimicrobial agents before skin incision in all cesarean section procedures (strong recommendation; high-quality evidence).
  • In clean and clean-contaminated procedures, do not administer additional prophylactic antimicrobial agent doses after the surgical incision is closed in the operating room (OR), even in the presence of a drain (strong recommendation; high-quality evidence).
  • Do not apply antimicrobial agents (ie, ointments, solutions, or powders) to the surgical incision with the aim of preventing SSI (strong recommendation; low-quality evidence).
  • Application of autologous platelet-rich plasma is not necessary for the prevention of SSI (weak recommendation; moderate-quality evidence suggesting a trade-off between clinical benefits and harms).
  • Consider the use of triclosan-coated sutures for the prevention of SSI (weak recommendation; moderate-quality evidence).
  • Implement perioperative glycemic control, and use blood glucose target levels lower than 200 mg/dL in patients with and without diabetes (strong recommendation; high- to moderate-quality evidence).
  • Maintain perioperative normothermia (strong recommendation; high- to moderate-quality evidence).
  • For patients with normal pulmonary function undergoing general anesthesia with endotracheal intubation, employ an increased fraction of inspired oxygen (FiO 2) during the surgical procedure and after extubation in the immediate postoperative period; to optimize tissue oxygen delivery, maintain perioperative normothermia and adequate volume replacement (strong recommendation; moderate-quality evidence).
  • Advise patients to shower or bathe the full body with either antimicrobial or nonantimicrobial soap or an antiseptic agent on at least the night before the day of the procedure (strong recommendation; accepted practice).
  • Perform intraoperative skin preparation with an alcohol-based antiseptic agent unless this is contraindicated (strong recommendation; high-quality evidence).
  • Application of a microbial sealant immediately after intraoperative skin preparation is not necessary for the prevention of SSI (weak recommendation; low-quality evidence).
  • The use of plastic adhesive drapes with or without antimicrobial properties is not necessary for the prevention of SSI. (weak recommendation; high- to moderate-quality evidence).
  • Consider intraoperative irrigation of deep or subcutaneous tissues with aqueous iodophor solution for the prevention of SSI; intraperitoneal lavage with aqueous iodophor solution is not necessary in contaminated or dirty abdominal procedures (weak recommendation; moderate-quality evidence).
  • Do not withhold transfusion of necessary blood products from surgical patients undergoing prosthetic joint arthroplasty as a means of preventing SSI (strong recommendation; accepted practice).
  • In clean or clean-contaminted prosthetic joint arthroplasties, do not administer additional antimicrobial prophylaxis doses after the surgical incision is closed in the OR, even in the presence of a drain (strong recommendation; high-quality evidence).

WHO Guidelines on Surgical Site Infection

In 2016, the World Health Organization (WHO) published the following guidelines regarding SSI [22] :

  • It is good clinical practice for patients to bathe or shower prior to surgery. Either plain soap or an antimicrobial soap may be used for this purpose.
  • Patients undergoing cardiothoracic and orthopedic surgery with known nasal carriage of S. aureus should receive perioperative intranasal applications of mupirocin 2% ointment with or without a combination of chlorhexidine gluconate (CHG) body wash.
  • Surgical antibiotic prophylaxis (SAP) should be administered prior to the surgical incision when indicated (depending on the type of operation). The panel recommends the administration of SAP within 120 min before incision, while considering the half-life of the antibiotic.
  • Preoperative oral antibiotics should be combined with mechanical bowel preparation to reduce the risk of SSI in adult patients undergoing elective colorectal surgery. Mechanical bowel preparation alone (without administration of oral antibiotics) should not be used for the purpose of reducing SSI in adult patients undergoing elective colorectal surgery.
  • In patients undergoing any surgical procedure, hair should either not be removed or, if absolutely necessary, should be removed only with a clipper. Shaving is strongly discouraged at all times, whether preoperatively or in the OR.
  • Alcohol-based antiseptic solutions are recommended based on CHG for surgical site skin preparation in patients undergoing surgical procedures.
  • Antimicrobial sealants should not be used after surgical site skin preparation for the purpose of reducing SSI.
  • Surgical hand preparation should be performed by scrubbing with either a suitable antimicrobial soap and water or using a suitable alcohol-based handrub before donning sterile gloves.
  • Consider the administration of oral or enteral multiple nutrient-enhanced nutritional formulas for the purpose of preventing SSI in underweight patients who undergo major surgical operations.
  • Do not discontinue immunosuppressive medication prior to surgery for the purpose of preventing SSI.
  • Adult patients undergoing general anesthesia with endotracheal intubation for surgical procedures should receive an 80% fraction of inspired oxygen intraoperatively and, if feasible, in the immediate postoperative period for 2-6 hr to reduce the risk of SSI.
  • Use triclosan-coated sutures for the purpose of reducing the risk of SSI, independent of the type of surgery.
  • Preoperative antibiotic prophylaxis should not be continued in the presence of a wound drain for the purpose of preventing SSI.

IDSA Guidelines on Surgical Site Infection

In 2014, the Infectious Diseases Society of America issued the following practice guidelines for the management of SSIs [21] :

  • Suture removal plus incision and drainage should be performed for SSIs (strong recommendation, low-quality evidence)
  • Adjunctive systemic antimicrobial therapy is not routinely indicated but, in conjunction with incision and drainage, may be beneficial for SSIs associated with a significant systemic response, such as erythema and induration extending more than 5 cm from the wound edge, temperature exceeding 38.5°C, heart rate higher than 110 beats/min, or white blood cell (WBC) count higher than 12,000/µL (weak recommendation, low-quality evidence)
  • A brief course of systemic antimicrobial therapy is indicated in patients with SSIs after clean operations on the trunk, head and neck, or extremities that also have systemic signs of infection (strong recommendation, low-quality evidence)
  • A first-generation cephalosporin or an antistaphylococcal penicillin for methicillin-sensitive  S aureus (MSSA)—or vancomycin, linezolid, daptomycin, telavancin, or ceftaroline where risk factors for methicillin-resistant  S aureus (MRSA) are high (nasal colonization, prior MRSA infection, recent hospitalization, or recent antibiotics)—is recommended (strong recommendation, low-quality evidence)
  • Agents active against gram-negative bacteria and anaerobes, such as a cephalosporin or fluoroquinolone in combination with metronidazole, are recommended for infections after operations on the axilla, gastrointestinal tract, perineum, or female genital tract (strong recommendation, low-quality evidence)