Quick reference guide

Issue date: October 2008

Surgical site infection

Prevention and treatment of surgical site infection

NICE clinical guideline 74

Developed by the National Collaborating Centre for Women’s and Children’s Health
 Surgical site infection

About this booklet

This is a quick reference guide that summarises the recommendations NICE has made to the
NHS in Surgical site infection: prevention and treatment of surgical site infection (NICE clinical
guideline 74). The guideline updates and replaces NICE technology appraisal guidance 24 (2001).

Who should read this booklet?

This quick reference guide is for all healthcare professionals who are involved in the care of patients
before, during and after surgery, including GPs, surgeons, nurses, tissue viability specialists and
other staff who care for patients who are at risk of, or have, surgical site infections.

Who wrote the guideline?

The guideline was developed by the National Collaborating Centre for Women’s and Children’s Health,
which is linked with the Royal College of Obstetricians and Gynaecologists. The Collaborating Centre
worked with a group of healthcare professionals (including consultants, GPs and nurses), patients
and carers, and technical staff, who reviewed the evidence and drafted the recommendations.
The recommendations were finalised after public consultation.
For more information on how NICE clinical guidelines are developed, go to www.nice.org.uk

Where can I get more information about the guideline?

The NICE website has the recommendations in full, reviews of the evidence they are based on,
a summary of the guideline for patients and carers, and tools to support implementation
(see pages 10 and 11 for more details).

National Institute for

Health and Clinical Excellence
© National Institute for Health and Clinical
MidCity Place
71 High Holborn Excellence, 2008. All rights reserved. This material
London may be freely reproduced for educational and
WC1V 6NA not-for-profit purposes. No reproduction by or
for commercial organisations, or for commercial
www.nice.org.uk purposes, is allowed without the express written
ISBN 1-84629-816-4 permission of NICE.

NICE clinical guidelines are recommendations about the treatment and care of people with specific
diseases and conditions in the NHS in England and Wales.
This guidance represents the view of NICE, which was arrived at after careful consideration of the
evidence available. Healthcare professionals are expected to take it fully into account when
exercising their clinical judgement. However, the guidance does not override the individual
responsibility of healthcare professionals to make decisions appropriate to the circumstances of
the individual patient, in consultation with the patient and/or guardian or carer, and informed
by the summary of product characteristics of any drugs they are considering.
Implementation of this guidance is the responsibility of local commissioners and/or providers.
Commissioners and providers are reminded that it is their responsibility to implement the guidance,
in their local context, in light of their duties to avoid unlawful discrimination and to have regard to
promoting equality of opportunity. Nothing in this guidance should be interpreted in a way that
would be inconsistent with compliance with those duties.
 Surgical site infection Contents

Contents
Key priorities for implementation 4

Information for patients and carers 5

Preoperative phase 6

Intraoperative phase 7

Postoperative phase 8

Glossary 9

Implementation tools 10

Further information 11

Introduction
G Surgical site infections compose up to 20% of all healthcare-associated infections. At least 5% of
patients undergoing surgery develop a surgical site infection.
G Surgical site infections can have a significant effect on quality of life for the patient. They are
associated with considerable morbidity and extended hospital stay.
G Surgical site infections result in a considerable financial burden to healthcare providers.
G Advances in surgery and anaesthesia have resulted in patients who are at greater risk of surgical
site infections being considered for surgery.
G The majority of surgical site infections are preventable and measures can be taken in the pre-,
intra- and postoperative phases of care to reduce risk of infection.
G It is important that healthcare professionals adhere to best practice to prevent and manage
surgical site infections.

Patient-centred care
Treatment and care should take into account patients’ individual needs and preferences. Good
communication is essential, supported by evidence-based information, to allow patients to reach
informed decisions about their care. Follow Department of Health advice on seeking consent if
needed. If the patient agrees, families and carers should have the opportunity to be involved in
decisions about treatment and care. If caring for young people in transition between paediatric and
adult services refer to ‘Transition: getting it right for young people’ (available from www.dh.gov.uk).

NICE clinical guideline 74 Quick reference guide 3

 Surgical site infection Key priorities for implementation

Key priorities for implementation

Information for patients and carers

G 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.

Preoperative phase
G Do not use hair removal routinely to reduce the risk of surgical site infection.
G 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.
G Give antibiotic prophylaxis to patients before:
– clean surgery involving the placement of a prosthesis or implant
– clean-contaminated surgery
– contaminated surgery.
G Do not use antibiotic prophylaxis routinely for clean non-prosthetic uncomplicated surgery.
G Use the local antibiotic formulary and always consider potential adverse effects when choosing
specific antibiotics for prophylaxis.
G Consider giving a single dose of antibiotic prophylaxis intravenously on starting anaesthesia.
However, give prophylaxis earlier for operations in which a tourniquet is used.

Intraoperative phase
G 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.
G Cover surgical incisions with an appropriate interactive dressing at the end of the operation.

Postoperative phase
G 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.

4 NICE clinical guideline 74 Quick reference guide

 Surgical site infection Information for patients and carers

Information for patients and carers

G Give patients and carers clear, consistent information and advice throughout their care including:
– the risks of surgical site infections
– what is being done to reduce risks
– how to care for their wound after the patient is discharged
– how to recognise a surgical site infection
– who to contact if they are concerned about possible surgical site infection
– how surgical site infections are managed.
G Use an integrated care pathway for healthcare-associated infections to help communicate
information.

NICE clinical guideline 74 Quick reference guide 5

 Surgical site infection Preoperative phase

Preoperative phase
Patient preparation
G 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.
G Give patients specific theatre wear, appropriate for the procedure and clinical setting, with easy access
to the operative site and for placement of devices. Consider also the patient’s comfort and dignity.

Do not use the following routinely to reduce the risk of surgical site infections:
G hair removal
G nasal decontamination with topical antimicrobial agents targeting Staphylococcus aureus
G mechanical bowel preparation.

Hair removal
G If hair has to be removed, use electric clippers with a single-use disposable head on the day of surgery.
G Do not use razors for hair removal, because they increase the risk of surgical site infection.

Antibiotic prophylaxis
G Give antibiotic prophylaxis to patients before:
– clean surgery involving placing a prosthesis or implant
– clean-contaminated surgery
– contaminated surgery.
G Do not give antibiotic prophylaxis routinely for clean non-prosthetic uncomplicated surgery.
G Use the local antibiotic formulary and consider potential adverse effects when choosing antibiotics.
G Consider the timing and pharmacokinetics of the antibiotic.
G Consider giving a single dose of antibiotic prophylaxis intravenously on starting anaesthesia or earlier
if a tourniquet is used.
G Give a repeat dose when the operation is longer than the half-life of the antibiotic.
G Give additional antibiotic treatment to patients having surgery on a dirty or infected wound.
G Whenever possible, inform patients before their operation if they will need antibiotic prophylaxis, and
afterwards if they have been given antibiotics.

Staff preparation
G All staff should wear specific non-sterile theatre wear in areas where operations are carried out.
G Movement of staff in and out of these areas should be kept to a minimum.
G Operating team staff should remove hand jewellery, artificial nails and nail polish before operations.

6 NICE clinical guideline 74 Quick reference guide

 Surgical site infection Intraoperative phase

Intraoperative phase
Operating team preparation
G The operating team should:
– wear sterile gowns in the operating theatre during the operation
– consider wearing two pairs of sterile gloves if there is a high risk of glove perforation and
contamination may have serious consequences
– wash their hands using an antiseptic surgical solution and use a single-use brush or pick to clean
the nails, so that hands and nails are visibly clean, prior to the first operation on the list
– wash their hands before subsequent operations, using an alcoholic hand rub or gel, or an
antiseptic surgical solution
– wash their hands again if they are soiled, using an antiseptic surgical solution.

Patient skin preparation

G Use an antiseptic preparation, such as povidone-iodine or chlorhexidine, to prepare the skin at the
surgical site immediately before incision.
G If diathermy is to be used, dry antiseptic skin preparations by evaporation and avoid pooling of
alcohol-based solutions.

Maintaining patient homeostasis

G During operations maintain:
– patient temperature (see the NICE guideline on inadvertent perioperative hypothermia, available at
www.nice.org.uk/CG065)
– optimal oxygenation, in particular give oxygen during major surgery and in the recovery period to
ensure haemoglobin saturation of above 95%, and
– adequate perfusion.

Wound dressings
G Cover surgical incisions with an appropriate interactive dressing at the end of the operation.

Do not use the following to reduce the risk of surgical site infections:
G non-iodophor-impregnated incise drapes. If an incise drape is required, use an iodophor-
impregnated drape unless the patient has an iodine allergy
G insulin routinely to optimise postoperative blood glucose levels in patients who do not
have diabetes
G diathermy for surgical incision
G wound irrigation
G intracavity lavage
G intraoperative skin redisinfection or topical cefotaxime in abdominal surgery.

NICE clinical guideline 74 Quick reference guide 7

 Surgical site infection Postoperative phase

Postoperative phase
Dressing and cleansing the wound
G Use an aseptic non-touch technique for changing or removing dressings.
G Use sterile saline for wound cleansing up to 48 hours after surgery.
G Advise patients that they may shower safely 48 hours after surgery.
G Use tap water for wound cleansing after 48 hours if the wound has separated or has been surgically
opened to drain pus.
G Use an interactive dressing for surgical wounds that are healing by secondary intention.
G Refer to a tissue viability nurse (or another healthcare professional with tissue viability expertise) for
advice on appropriate dressings for surgical wounds that are healing by secondary intention.

Do not use the following to reduce the risk of surgical site infections:
G topical antimicrobial agents for surgical wounds that are healing by primary intention

G Eusol and gauze, or moist cotton gauze or mercuric antiseptic solutions for surgical wounds that
are healing by secondary intention.

Antibiotic treatment
G If a surgical site infection is suspected (i.e. cellulitis), either de novo or because of treatment failure,
give the patient an antibiotic.
G Choose an antibiotic that covers the most likely causative organisms. Consider local resistance
patterns and the results of microbiological tests.

Debridement
G Do not use Eusol and gauze, or dextranomer or enzymatic treatments for debridement of surgical
site infections.

Specialist wound care services

G To improve the management of surgical wounds:
– use a structured approach to care (including preoperative assessment to identify patients with
potential wound healing problems)
– provide enhanced education to healthcare professionals, patients and carers, and share
clinical expertise.

8 NICE clinical guideline 74 Quick reference guide

 Surgical site infection Glossary

Glossary
Debridement The excision or wide removal of all dead (necrotic) and damaged tissue, that may
develop in a surgical wound.
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 surgical 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.
Surgical wound classification
G Clean: an incision in which no inflammation is encountered in a surgical procedure, without a break
in sterile technique, and during which the respiratory tract, alimentary or genitourinary tracts are
not entered.
G Clean-contaminated: an incision through which the respiratory, alimentary, or genitourinary tract is
entered under controlled conditions but with no contamination encountered.
G 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.
G 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.

NICE clinical guideline 74 Quick reference guide 9

 Surgical site infection Implementation tools

Implementation tools
NICE has developed tools to help organisations G Audit support for monitoring local practice.
implement this guidance (listed below). G A costing statement to help estimate the
These are available on our website
costs and savings involved in implementing
(www.nice.org.uk/CG074).
this guideline.
G Slides highlighting key messages for local
discussion.

10 NICE clinical guideline 74 Quick reference guide

 Surgical site infection Further information

Further information
Ordering information Related NICE guidance
You can download the following documents from For information about NICE guidance that has
www.nice.org.uk/CG074 been issued or is in development, see the website
G
(www.nice.org.uk).
A quick reference guide (this document) –
a summary of the recommendations for Published
healthcare professionals. G Inadvertant perioperative hypothermia:

G The NICE guideline – all the recommendations. The management of inadvertant perioperative
hypothermia in adults. NICE clinical
G ‘Understanding NICE guidance’ – information guideline 65 (2008). Available from
for patients and carers. www.nice.org.uk/CG065
G The full guideline – all the recommendations, G Infection control: Prevention of healthcare-
details of how they were developed, and associated infection in primary and community
reviews of the evidence they were based on. care. NICE clinical guideline 2 (2003).
For printed copies of the quick reference guide or Available from www.nice.org.uk/CG002
‘Understanding NICE guidance’, phone NICE
publications on 0845 003 7783 or email Updating the guideline
[email protected] and quote: This guideline will be updated as needed, and
information about the progress of any update
G N1701 (quick reference guide)
will be posted on the NICE website
G N1702 (‘Understanding NICE guidance’). (www.nice.org.uk/CG074).

NICE clinical guideline 74 Quick reference guide 11

National Institute for
Health and Clinical Excellence
MidCity Place
71 High Holborn
London
WC1V 6NA

www.nice.org.uk

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ISBN 1-84629-816-4