• Surgical site infection (SSI) is a type of healthcare-associated infection in which a wound infection occurs after an invasive (surgical) procedure.

• Approximately 5% of patients undergoing a surgical procedure develop an SSI (NICE,2020)

• This guideline makes recommendations for the prevention of SSIs based on evidence-based guidance such as that from the OneTogether collaboration (2024) and NICE (2020) Guideline 125 ‘Surgical Site Infections: Prevention and treatment’.

This is a controlled document. If you are using a printed copy, check it against the guidelines site to ensure you are using the latest edition. Print copies must be destroyed after use.

Abbreviations

Surgical site infection (SSI) is a type of healthcare-associated infection that occurs in the part of the body where a surgery took place. (CDC 2024). Other types of healthcare-associated infections that mainly affect surgical patients are postoperative respiratory and urinary tract infections, bacteraemia and antibiotic-related diarrhoea (particularly Clostridiodes difficile Infection). SSIs have been shown to compose up to 15.7% of all of healthcare-associated infections (NICE 2023).

• At least 5% of patients undergoing a surgical procedure develop a surgical site infection.

• SSIs can range from a spontaneously limited wound discharge to a life-changing or life-threatening postoperative complication. (NICE,2020)

• SSIs can have a significant effect on quality of life for the patient, are associated with considerable morbidity, extended hospital stay and considerable financial burden to healthcare providers (NICE,2020).

Advances in surgery and anaesthesia have resulted in patients who are at greater risk of surgical site infections being considered for surgery. In addition, increased numbers of infections are now being seen in primary care because patients are allowed home earlier following day case and fast-track surgery.

Most SSIs are caused by contamination of an incision with microorganisms from the patient’s own body during surgery. Infection caused by microorganisms from an outside source following surgery is less common. The majority of SSIs are preventable, and measures can be taken in the pre-, intra- and postoperative phases of care to reduce risk of infection.

This guideline makes recommendations for the prevention of SSIs based on evidence-based guidance such as that from the One Together collaboration (2024) and NICE (2020) Guideline 125 ‘Surgical Site Infections: Prevention and treatment’.

2.1 Assessment of infection risk

• Patients should be reviewed for infection risks prior to surgery using the Communicable Disease screening tool on Epic®.

• Wherever possible, identify and treat any infections remote to the surgical site before elective surgery, which may require postponing of surgery until the infection has resolved.

• There is no need to screen for asymptomatic bacteriuria (see Eolas).

2.2 Patient information

 Patients and carers must be offered 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.

 For operation categories included in mandatory surgical site surveillance, patients should be given a leaflet on monitoring surgical sites for infection (UKHSA 2022) at preoperative assessment.

2.3 MRSA screening and suppression

 Preoperative MRSA screening must take place for patients who fit the criteria set in IPC06 ‘Guidelines for MRSA’.

 Patients who are known to be colonised with MRSA or other multidrug-resistant organisms must be source isolated in single rooms when admitted to Surgical and Orthopaedic wards.

 Refer to the Frimley Health Eolas for suppression treatment of MRSA colonisation and infection.

For patients planned for elective Orthopaedic implant surgery:

 Patients with a diagnosis of eczema/ psoriasis and/or have a chronic skin disorder (such as excessively dry skin), should receive a 5-day course of Octenisan body wash and mupirocin nasal ointment prior to being admitted for elective Orthopaedic implant surgery.

 The pre-operative team should check electronic patient records including connected care for prescriptions of skin treatment and diagnosis of chronic skin conditions.

 Patients with severe skin conditions should seek GP advice or be referred for specialist dermatology where necessary to advise optimal management of skin condition prior to admission.

2.4 Pre-operative Washing

 Advise patients to shower or have a bath (or be assisted to shower, bath or bed bath) using soap, either the day before, or on the day of surgery.

 Prior to elective admissions, patients should be given verbal and written information about washing prior to surgery.

 The patient wash should be documented in the pre-operative checklist.

 There is a defined process for assisting patients who are unable to wash themselves.

 Pre-operative washing with Octenisan body wash is recommended (NHSE GIRFT 2025) for the following elective patient groups, and the wash (and patient information leaflet) will be provided at pre-operative assessment for use the day before and on the day of surgery:

• All patients who are having surgery that require an implantable device

• All patients undergoing major orthopaedic (eg. arthroplasty and spinal operations) and cardiothoracic surgery (eg. coronary artery bypass surgery)

• All patients where there is surgical concern of increased risk of surgical site infection (SSI) which should be locally defined ‘at risk’ groups.

2.5 Hair removal

 Do not use hair removal routinely to prevent the risk of surgical site infection.

 Pre-operatively patients are given verbal and written documentation not to shave or remove hair from the planned operation site including why this is important and how to ask for help.

 Hair removal must only take place if the surgeon is unable to visualise the operative site.

 Razors should not be used for hair removal because they increase the risk of SSI. If hair removal is needed, then clippers with disposable heads must be used.

 Hair is removed as near to the time of incision as possible and not in the operating theatre.

2.6 Patient theatre wear

 Patients’ theatre wear should be appropriate for the procedure and the clinical setting, and allows access to the surgical site, areas for device insertion, and also maintains the patient’s privacy and dignity.

2.6 Preoperative warming

• Prior to elective admissions patients should be given verbal and written information on the importance of keeping warm.

• Patients risk of hypothermia is to be assessed pre-operatively and recorded.

• The patients core temperature is measured and recorded within 1hour of being transferred to theatres.

• The patient’s temperature should be 36°C or above before they are transferred to the operating department.

• Infrared thermometers and forehead strip thermometers should not be used to measure temperature in adults before, during and after surgery.

2.7 Mechanical bowel preparation

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

2.8 Decontamination of medical devices/ surgical equipment

 Instruments must be decontaminated and sterilised in a credited central sterilisation unit which is compliant to quality management systems.

 An instrument traceability system must be in use.

 Defined mechanisms must be in place for recognising sterile integrity of instrumentation. All pre-sterilised instruments must be checked for evidence that they have been sterilised and that the packs are intact.

 Sterile instruments are stored in a clean, dry, dust free environment.

3.1 Surgical Practice

 Operating staff must be trained and assessed as competent in performing surgical hand hygiene and donning and doffing of personal protective equipment (PPE).

 Operating staff must perform surgical hand hygiene and donning of PPE, based on a risk assessment, correctly immediately prior to commencing surgery.

 Operating staff are trained and assessed as competent in the maintenance and management of the sterile field.

3.2 Skin preparation

 NICE (2020) recommends that the skin should ideally be disinfected immediately prior to the incision with 2% chlorhexidine/ 70% alcohol, or alcoholic povidone-iodine, unless contra-indicated.

 All products used for skin disinfection must be intended for use as a surgical skin disinfectant and must also have an associated management protocol, e.g. multi-dose bottles must have date and time of opening and use by date.

 There is a defined skin disinfection process agreed by a multi-disciplinary team that states the specific agent, application method, timing and person responsible.

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

 Do not apply topical antimicrobial agents to the skin incision.

Choices for skin preparation: Refer to the OneTogether (2023) Surgical Skin Preparation Decision Guide Surgical Skin Preparation Decision Guide

Note: Products used should be authorised for use as pre-operative skin cleaning/ disinfection prior to invasive medical procedures – if not, the prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented.

3.3 Preventing skin re-colonisation.

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

 For surgical procedures where an incise drape is required, an iodophor-impregnated drape unless the patient has an iodine allergy. (NICE 2020).

3.4 Antibiotic prophylaxis

 The local Eolas must be used, and always consider potential adverse effects when choosing specific antibiotics for prophylaxis.

 Do not use antibiotic prophylaxis for clean, non-prosthetic, uncomplicated surgery.

 Use antibiotics only when indicated and for the recommended duration.

 Always check for previous colonisation or infection with multidrug-resistant organisms (from notes, IT systems, asking the patient), which may have an impact on antibiotics that can be prescribed.

 Surgical prophylaxis, when required, should be given intravenously on induction of anaesthesia or within 60 minutes before the incision is made.

 Give antimicrobial treatment (in addition to prophylaxis) to patients having surgery on a dirty or infected wound as per the trust Eolas.

 A single dose of prophylactic antibiotics is administered unless surgery is prolonged or there is another specific indication for a repeat dose.

3.5 Maintaining patient homeostasis.

3.5.1 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. To optimize tissue oxygen delivery, maintain perioperative normothermia and adequate volume replacement.

3.5.2 Perioperative warming

 Patients should be adequately covered to conserve heat and exposed only during surgical preparation.

 The patient’s temperature should be documented before induction of anaesthesia and then every 30 minutes until the end of surgery. If below 36°C, then anaesthesia should not commence, unless there is a need to expedite surgery.

 Patients having anaesthesia for longer than 30 minutes, or are at a higher risk of perioperative hypothermia, are warmed from induction using forced-air warming.

 Intravenous fluids (500 ml or more) and blood products should be warmed to 37°C using a fluid warming device.

 All irrigation fluids used intra-operatively should be warmed in a thermostatically controlled cabinet to a temperature of 38–40°C.

3.5.3 Glycaemic Control

Maintain intra-operative glycaemic control in both diabetic and non-diabetic patients, targeting blood glucose levels of <200mg/dL.

3.6 Instrument management

 Instruments should be laid up in a clean area, as close to the procedure time as possible, and protected from contamination prior to use. All prepared instruments must be closely observed at all times.

 There must be a defined process to change instruments if contamination is identified.

3.7 Management of theatre personnel

 Staff in the operating theatre must be dressed in a manner to enable effective hand hygiene: short, clean nails, without nail polish or false nails, no stoned rings or wristwatches.

 Staff must adhere to the standard IPC precautions ( NHSE 2024)

 The doors to the operating theatre should remain closed and traffic in and out of theatre restricted to a minimum to ensure efficiency of the ventilation.

 The number of personnel present in theatre should be kept to a minimum.

3.8 Theatre Environment

 The required air pressure and ventilation systems across the operating theatre (including anaesthetic and scrub rooms) must be defined.

 Any issues with Theatre ventilation must be reported to the Estates team immediately.

 Facilities and Estates are responsible for the organisation of annual maintenance and re-validation of Theatres, and commissioning of any new Theatres.

 There is a defined process to ensure all equipment is being cleaned prior to being bought into theatres.

 The theatre is kept free from clutter and unnecessary equipment.

 Thorough environmental and equipment decontamination is conducted in between cases.

4.1 Wound management

 Surgical incisions should be covered with an appropriate interactive dressing at the end of the operation.

 Use an aseptic, non-touch technique for changing and removing dressings.

 Keep the frequency of dressing changes to a minimum to avoid disrupting healing tissue.

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

 Exposed surgical wounds should not be washed in the shower to avoid acquiring pathogens from water outlets until the wound is completely healed.

 Ensure dressing changes are kept to a minimum.

 Advice patients that they can shower safely 48 hours after surgery with the wound covered and dressing changed after shower.

 Do not use topical antimicrobial agents for surgical wounds that are healing by primary intention.

 Refer the patient to wound care specialists if required for advice on appropriate dressings and care.

 Dressing choice should be considered to optimise healing and avoid complications such as blistering.

 There should be a surgical wound management plan for all procedures that include the use of any wound drain.

 Negative pressure wound dressings should be considered as an option for closed surgical incisions in people who are at high risk of developing surgical site infections (NICE 2019).

4.2 Post-operative patient warming

 The patient’s temperature is measured and recorded every 15 minutes in recovery.

 Patients with temperature less than 36°C are warmed with forced air warming, until their temperature reaches a normothermic level.

 Patients are only returned to the ward when their temperature is normothermic.

4.3 Patient information

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

 Always inform patients after their operation if they have been administered antibiotics (NICE 2019).

 The risk of SSI should be monitored using a standardised surveillance methodology to provide feedback to surgeons and the surgical team about the quality of infection prevention in the operating theatre.

 Monitoring of infection rates is essential to provide patients with accurate information about the risk of SSI associated with the operation.

 FHFT carries out and submits surveillance data for all operations in the category of hip and knee replacement surgery, as part of the UKHSA (2013) Mandatory Surgical Site Surveillance. The collection of data is multi-disciplinary, to ensure a high-level ownership by all departments involved with the cases.

 High or increased rates (or unusually low rates) are investigated and appropriate action taken to address any problems identified.

 Formal post-infection review is carried out for all deep SSIs of primary hip and knee replacements.

This guideline is monitored through mandatory surgical site infection surveillance, participation in Getting It Right First Time (GIRFT) national surveys, the IPC Annual Audit and Surveillance programme, and through review of SSI incidents and/ or complaints.