1. Preoperative preparation of the patient

a. Adequately control serum blood glucose level in all diabetic patients before elective operation and maintain blood glucose level 200 mg/dl during the operation and in the immediate postoperative period (48 hours). Category IB

b. Always encourage tobacco cessation. At minimum, instruct patients to abstain for at least 30 days before elective operation from smoking cigarettes, cigars, pipes or any other form of tobacco consumption (e.g., chewing/dipping). Category IB

c. No recommendation to taper or discontinue steroid use (when medically permissible) before elective operation. Unresolved issue

d. Consider delaying an elective operation in a severely malnourished patient. A good predictor of nutritional status is serum albumin. Category II

e. Attempt weight reduction in obese patients before elective operation. Category II

f. Identify and treat all infections remote to the surgical site before elective operation. Do not perform elective operations in patients with remote site infections. Category IA

g. Keep preoperative hospital stay as short as possible. Category IA

h. Prescribe preoperative showers/baths with an antiseptic agent the night before and the morning of the operation. Category IB

i. Do not remove hair preoperatively unless the hair at or around the incision site will interfere with the operation. Category IA

j. If hair is removed, it should be removed immediately before the operation using electric clippers rather than razors or depilatories. Category IA

k. Thoroughly wash and clean at and around the incision site to remove gross contamination before performing antiseptic skin preparation. Category IB

l. Use an acceptable antiseptic agent for skin preparation, such as alcohol (usually 70%-92%), chlorhexidine (4%, 2%, or 0.5% in alcohol base), or iodine/iodophors (usually 10% aqueous with 1% iodine or formulation with 7.5%). Category IB

m. Apply preoperative antiseptic skin preparation in concentric circles moving out toward the periphery. The prepped area must be large enough to extend the incision or create new incisions or drain sites, if necessary. Category IB

2. Preoperative Hand/Forearm Antisepsis

All members of the surgical team:

a. Keep nails short and do not wear artificial nails. Category IB

b. No recommendation on wearing nail polish. Unresolved Issue

c. Do not wear hand/arm jewelry. Category II

d. Perform a preoperative surgical scrub that includes hands and forearms up to the elbows before the sterile field, sterile instruments, or the patient's prepped skin is touched. Category IB

e. Clean underneath each fingernail prior to performing the surgical scrub. Category IB

f. Perform the surgical scrub for a duration of 3-5 minutes. Category IB

g. After performing the surgical scrub, keep hands up and away from the body (elbows in flexed position) so that water runs from the tips of the fingers toward the elbows. Dry hands with a sterile towel and don a sterile gown and gloves. Category IB

3. Antimicrobial Prophylaxis

a. Select a prophylactic antimicrobial agent based on its efficacy against the most common pathogens causing SSI for a specific operation. Category IA

b. Administer the antimicrobial prophylactic agent by the intravenous route except for colorectal operations. In colorectal operations the antimicrobial agent is administered orally, or a combination of oral and intravenous route is used. Category IA

c. Administer the antimicrobial agent before the operation starts to assure adequate microbiocidal tissue levels before the skin incision is made, ideally antimicrobial prophylaxis should be administered within 30 minutes before, but not longer than 2 hours before, the initial incision. Category IA

d. For cesarean section, administer prophylaxis immediately after the umbilical cord is clamped. Category IA

e. Administer prophylactic antimicrobial agent as close as possible to the time of induction of anesthesia. Category II

f. Do not extend prophylaxis postoperatively. Category IB

g. Consider additional intraoperative doses under the following circumstances: (1) operations whose duration exceeds the estimated serum half-life of the agent, (2) operations with major intraoperative blood loss, and (3) operations on morbidly obese patients. Category IB

h. Do not routinely use vancomycin for prophylaxis. Category IB

4. Intraoperative Issues

4-1. Operating Room Environment

A. Ventilation

a. Maintain positive-pressure ventilation in the operating room with respect to the corridors and adjacent areas. Category IB

b. Maintain a minimum of 15 air changes per hour, of which at least 3 should be fresh air. Category IB

c. Filter all air, recirculated and fresh, through the appropriate filters per the American Institute of Architects recommendations. Category IB

d. Introduce all air at the ceiling and exhaust near the floor. Category IB

e. No recommendation for the use of laminar flow ventilation or ultraviolet lights in the operating room to prevent SSI. Unresolved issue

f. Keep operating room doors closed except as needed for passage of equipment, personnel, and the patient. Category IB

g. Limit the number of personnel entering the operating room to necessary personnel. Category IB

B. Cleaning and Disinfection of Environmental Surfaces

a. No recommendation on disinfecting operating rooms between operations in the absence of visible soiling of surfaces or equipment. Unresolved issue

b. When visible soiling or contamination, with blood or other body fluids, of surfaces or equipment occurs during an operation, use an EPA-approved hospital disinfectant to clean the affected areas before the next operation. Category IB*

c. Wet vacuum the operating room floor after the last operation of the day or night with an EPA-approved hospital disinfectant. Category IB

d. Do not perform special cleaning or disinfection of operating rooms after contaminated or dirty operations. Category IA

e. Do not use tacky mats at the entrance to the operating room suite for infection control; this is not proven to decrease SSI risk. Category 1A

C. Microbiologic Sampling

Do not perform routine environmental sampling of the operating room. Perform microbiologic sampling of operating room environmental surfaces or air only as part of an epidemiologic investigation. Category IB

D. Sterilization of Surgical Instruments

a. Sterilize all surgical instruments according to published guidelines. Category IB

b. Perform flash sterilization only in emergency situations. Category IB

c. Do not use flash sterilization for routine reprocessing of surgical instruments. Category IB

4-2. Surgical Attire and Drapes

a. No recommendations on how or where to launder scrub suits, on restricting use of scrub suits to the operating suite or for covering scrub suits when out of the operating suite. Unresolved issue

b. Change scrub suits when visibly soiled, contaminated and/or penetrated by blood or other potentially infectious materials. Category IB*

c. Wear a surgical mask that fully covers the mouth and nose when entering the operating room if sterile instruments are exposed, or if an operation is about to begin or already under way. Wear the mask throughout the entire operation. Category IB*

d. Wear a cap or hood to fully cover hair on the head and face when entering the operating room suite. Category IB*

e. Do not wear shoe covers for the prevention of SSI. Category IA

f. Wear shoe covers when gross contamination can reasonably be anticipated. Category II*

g. The surgical team must wear sterile gloves, which are put on after donning a sterile gown. Category IB*

h. Use materials for surgical gowns and drapes that are effective barriers when wet. Category IB

4-3. Practice of Anesthesiology

Anesthesia team members must adhere to recommended infection control practices during operations. Category IA

4-4. Surgical Technique

a. Handle tissue gently, maintain effective hemostasis, minimize devitalized tissue and foreign bodies (i.e., sutures, charred tissues, necrotic debris), and eradicate dead space at the surgical site. Category IB

b. Use delayed primary closure or leave incision open to close by secondary intention, if the surgical site is heavily contaminated (e.g., Class III and Class IV). Category IB

c. If drainage is deemed necessary, use a closed suction drain. Place the drain through a separate incision, rather than the main surgical incision. Remove the drain as soon as possible. Category IB

5. Postoperative Surgical Incision Care

a. Protect an incision closed primarily with a sterile dressing for 24-48 hours postoperatively. Also ensure that the dressing remains dry and that it is not removed bathing. Category IA

b. No recommendation on whether or not to cover an incision closed primarily beyond 48 hours, nor on the appropriate time to shower/bathe with an uncovered incision. Unresolved Issue

c. Wash hands with an antiseptic agent before and after dressing changes, or any contact with the surgical site. Category IA

d. For incisions left open postoperatively, no recommendation for dressing changes using a sterile technique vs. clean technique. Unresolved Issue

e. Educate the patient and family using a coordinated team approach on how to perform proper incision care, identify signs and symptoms of infection, and where to report any signs and symptoms of infection. Category II

6. Surveillance

a. Use CDC definitions of SSI without modification for identifying SSI among surgical inpatients and outpatients. Category IB

b. For inpatient case-finding, use direct prospective observation, indirect prospective detection, or a combination of both direct and indirect methods for the duration of the patient's hospitalization, and include a method of post-discharge surveillance that accommodates available resources and data needs. Category IB

c. For outpatient case-finding, use a method that accommodates available resources and data needs. Category IB

d. For each patient undergoing an operation chosen for surveillance, record those variables shown to be associated with increased SSI risk (e.g., surgical wound class, ASA class, and duration of operation). Category IB

e. Upon completion of the operation, a surgical team member assigns the surgical wound classification. Category IB

f. Periodically calculate operation-specific SSI rates stratified by variables shown to be predictive of SSI risk. Category IB

g. Report appropriately stratified, operation-specific SSI rates to surgical team members. The optimum frequency and format for such rate computations will be determined by stratified case-load sizes and the objectives of local, continuous, quality improvement initiatives. Category IB