Practice Guidelines

Prevention and treatment of surgical site infection: summary of NICE guidance

BMJ 2008; 337 doi: http://dx.doi.org/10.1136/bmj.a1924 (Published 28 October 2008) Cite this as: BMJ 2008;337:a1924
  1. David Leaper, visiting professor1,
  2. Shona Burman-Roy, systematic reviewer 2,
  3. Ana Palanca, research assistant 2,
  4. Katherine Cullen, health economist2,
  5. Danielle Worster, information scientist 2,
  6. Eva Gautam-Aitken, project manager2,
  7. Martin Whittle, clinical codirector2
  8. On behalf of the Guideline Development Group
  1. 1Department of Wound Healing, Cardiff University, Cardiff
  2. 2National Collaborating Centre for Women’s and Children’s Health, London W1T 2QA
  1. Correspondence to: D Leaper, National Collaborating Centre for Women’s and Children’s Health, King’s Court, 2-16 Goodge Street, London W1T 2QA profdavidleaper{at}doctors.org.uk

    Why read this summary?

    The consequences of infection at the site of surgery can be devastating to the patient and costly to manage, often requiring readmission to hospital. Surgical site infections account for 14% of all healthcare acquired infections.1 This article summarises the most recent guidance from the National Institute for Health and Clinical Excellence (NICE) for the prevention and management of surgical site infection.2

    Recommendations

    NICE recommendations are based on systematic reviews of best available evidence. When minimal evidence is available, recommendations are based on the guideline development group’s opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.

    Information for patients and carers

    Provide patients and carers with clear and consistent, easily understood information and advice throughout all stages of their care. Information should include:

    • The risks of surgical site infections, how to prevent them, and how they are managed using an integrated care pathway

    • How to recognise a surgical site infection and who to contact if they are concerned

    • How to care for their wound after discharge from hospital.

    • Whether they have been given antibiotics before or after an operation.

    [All these recommendations are based on a high quality randomised controlled trial and on the opinion of the Guideline Development Group]

    Preoperative phase

    Showering

    • Advise patients to shower or have a bath using soap (or help them with this) either the day before, or on the day of, surgery.

    Hair removal

    • Do not use hair removal routinely to reduce the risk of surgical site infection. [Based on a high quality systematic review of randomised controlled trials]

    • If hair removal is necessary, use electric clippers with a single-use head on the day of surgery rather than razors, which increase risk of surgical site infection. [Based on a high quality systematic review of randomised controlled trials and a cost-effectiveness analysis]

    Theatre wear

    • Give patients specific theatre wear that is practicable for the operation, with consideration for their comfort and dignity.

    • Staff should wear specific non-sterile theatre wear in all operating areas and keep their movements in and out of these areas to a minimum.

    • The operating team must remove artificial nails and nail polish, and where possible, hand jewellery, before operations.

    Nasal decontamination

    • Do not routinely use nasal decontamination with topical antimicrobial agents aimed at eliminating Staphylococcus aureus to reduce the risk of surgical site infection.

    Mechanical bowel preparation

    • Do not use mechanical bowel preparation routinely to reduce the risk of surgical site infection. [Based on a high quality meta-analysis of small to medium sized randomised controlled trials]

    Antibiotic prophylaxis and treatment

    • Give antibiotic prophylaxis to patients before:

      • -Clean surgery involving the placement of a prosthesis or implant

      • -Clean-contaminated surgery

      • -Contaminated surgery.

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

    • Consider giving a single intravenous dose of antibiotic prophylaxis on starting anaesthesia, or earlier for operations in which a tourniquet is used. Repeat the dose if the operation is longer than the half life of the antibiotic given.

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

    [All four recommendations based on randomised controlled trials and meta-analysis of randomised controlled trials3 and on the opinion of the Guideline Development Group]

    Intraoperative phase

    Hand decontamination

    • Before the first operation the members of the operating team should wash their hands with antiseptic surgical solution, using a single-use brush or pick for the nails, and should ensure that hands and nails are visibly clean.

    • Before subsequent operations, wash hands with either an alcoholic hand rub or an antiseptic surgical solution. If hands are soiled then wash them again with an antiseptic surgical solution.

    Sterile gowns and gloves

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

    • Consider wearing two pairs of sterile gloves when there is a high risk of glove perforation and the consequences of contamination are serious.

    Incise drapes

    • If an incise drape is required, use one that is impregnated with iodophore unless the patient has an iodine allergy.

    Antiseptic skin preparation

    • Prepare the skin at the surgical site immediately before incision using an aqueous or alcohol based antiseptic preparation (povidone iodine or chlorhexidine are most suitable). [Based on a meta-analysis of several small and medium sized randomised controlled trials]

    Diathermy

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

    Maintaining patient homoeostasis

    • Maintain adequate perfusion, oxygenation, and temperature control during surgery.

    • Do not give insulin routinely to patients who do not have diabetes to reduce risk of surgical site infection by optimising postoperative blood glucose levels.

    Wound irrigation and intracavity lavage

    • Do not use wound irrigation or intracavity lavage to reduce the risk of surgical site infection.

    Antiseptic and antimicrobial agents before wound closure

    • Do not repeat skin disinfection during an operation or use topical cefotaxime in abdominal surgery to reduce the risk of surgical site infection.

    Wound dressings

    • Cover surgical incisions with an appropriate interactive dressing at the end of the operation. [Based on several low quality randomised controlled trials and on the opinion of the Guideline Development Group]

    Postoperative phase

    Postoperative cleansing and dressing changes

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

    • Use an “aseptic” non-touch technique for changing or removing surgical wound dressings.

    • For wound cleansing, use sterile saline up to 48 hours after surgery. Use tap water after 48 hours if the surgical wound has separated or has been surgically opened to drain pus.

    Wound healing by primary intention

    • Do not use topical antimicrobial agents to reduce the risk of surgical site infection.

    Wound healing by secondary intention

    • Refer to a tissue viability nurse (or another healthcare professional with tissue viability expertise) for advice on appropriate interactive dressings. [Based on several low quality, small randomised controlled trials]

    • Do not use chlorinated solutions (such as Eusol) and gauze; moist cotton gauze; or mercuric antiseptic solutions.

    Management of surgical site infection

    • When surgical site infection is suspected, either de novo or because of treatment failure, use an antibiotic that covers the likely causative organisms, taking into consideration local resistance patterns and the results of microbiological tests.

    • If debridement is required, do not use chlorinated solutions, gauze, dextranomer, or enzymatic treatments.

    Specialist wound care services

    Although no direct evidence exists to support the provision of specialist wound care services for managing surgical wounds that are difficult to heal, a structured approach to care (including preoperative assessments to identify individuals with potential wound healing problems) is necessary for improving overall management of surgical wounds. To support this structured approach, better education of healthcare workers, patients, and carers, and sharing of clinical expertise will be needed.

    Overcoming barriers

    Although the seriousness of surgical site infection is recognised, reduction of its incidence requires an understanding of several complex issues. For example, surgical operations involve different anatomical sites, are done for different clinical reasons, and may be performed in various locations.

    Understanding the significance of surgical site infection requires surveillance using clear definitions and methods, and standardisation of these is currently lacking. The reduction in the rates of surgical site infection has relied on strict surgical discipline, and the evidence base for many measures is generally weak and contains data from a range of heterogeneous procedures and circumstances. There is plainly a need for research projects to improve the evidence base, preferably from multicentre randomised controlled trials.

    The use of antibiotic prophylaxis is evidently effective in reducing the incidence of surgical site infection, but the potential cost in terms of antibiotic resistance may be high and needs to be defined. The importance of tissue viability experts in the management of complicated surgical site infections is clear, but implementation of the wound healing recommendations will require adequate resources to train appropriate healthcare professionals.

    Further information on the guidance

    In the absence of adequate research, many of the procedures during surgery are based on accepted, often ritualistic practice to minimise risks to both patients and staff. Nevertheless, variations in practice exist throughout the surgical care pathway. Most of these inconsistencies relate to use of antiseptic, antibiotic, and other anti-infective agents during routine perioperative activities. Individual patient characteristics as well as the type and duration of procedure also bring independent risks to surgery, and hence other practice variations reflect the balance of clinical and patient outcomes requiring consideration.

    As surgical site infection can be a life threatening result of surgery, it is important to distinguish those practices that reduce the risk of surgical site infection from those that are done according to the individual preferences of the patient or surgical team (for example, to improve surgical technique, patient comfort, cosmetic result).

    Considerable variation in practice in the preoperative, intraoperative, and postoperative phases of surgery is likely to continue unless standardisation of practice across the NHS is introduced using an evidence based model.

    Methods

    The guidance was developed by the National Collaborating Centre for Women’s and Children’s Health in accordance with NICE guideline development methods (www.nice.org.uk/aboutnice/howwework/developingniceclinicalguidelines/developing_nice_clinical_guidelines.jsp).

    The collaborating centre established a Guideline Development Group consisting of healthcare professionals, representatives for patients and carers, and experts in guideline methodology from the collaborating centre. Membership of the Guideline Development Group included two surgeons, a tissue viability nurse, two microbiologists, a theatre nurse, a surveillance coordinator, an infection control specialist, and two patient representatives.

    Evidence was identified from the consultation draft previously prepared by the National Collaborating Centre for Nursing and Supportive Care, from searches performed by the information scientist at the National Collaborating Centre for Women’s and Children’s Health Collaborating Centre, and from the Guideline Development Group. The development group appraised clinical evidence and evaluated cost effectiveness of interventions where possible. A draft of the guideline was provided for stakeholder organisations to submit comments on. The draft was later revised to take account of comments received. Future updates of the guidance will be prepared as part of the NICE guideline development programme.

    Areas for future research

    Definitions, surveillance, and risk factors
    • Would a risk assessment tool developed by consensus methodology help predict the risk of surgical site infection?

    Preoperative phase
    • Is it cost effective to use mupirocin for nasal decontamination? In which patients is it most effective?

    Intraoperative phase
    • What is the cost effectiveness of new materials used in reusable and disposable operative drapes and gowns in reducing the incidence of surgical site infection?

    • What is the value of supplemented oxygenation in the recovery room in the prevention of surgical site infection? What are the likely mechanisms of action?

    • What are the possible benefits of improved postoperative blood glucose control to the incidence of surgical site infection?

    • Does irrigation with modern antiseptics and saline under pressure, with or without added antiseptics, in a broader range of surgery allow the development of a strategy less dependent on antibiotic prophylaxis to reduce the incidence of surgical site infection?

    • Does the use of antiseptic products applied to the wound before closure in elective, clean non-prosthetic surgery reduce the reliance on antibiotic prophylaxis for reducing the incidence of surgical site infection?

    • What is the cost effectiveness of collagen implants with antibiotics or antiseptics in reducing the incidence of surgical site infection?

    • What types of closure methods will reduce the risk of surgical site infection?

    • What are the benefits and cost effectiveness of different types of post-surgical interactive dressings for the reduction of surgical site infection?

    Postoperative phase
    • What are the most appropriate methods of chronic wound care (including alginates, foams, hydrocolloids, and dressings containing antiseptics such as antimicrobial honey, cadexomer, iodine, or silver) in managing surgical site infection as well as patient outcomes?

    • What is the effectiveness of modern methods of debridement in surgical wounds healing by secondary intention?

    Notes

    Cite this as: BMJ 2008;337:a1924

    Footnotes

    • This is one of a series of BMJ summaries of new guidelines, which are based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.

    • The members of the Guideline Development Group are Mark Collier, tissue viability lead nurse consultant; David Evans, patient representative; Mark Farrington, consultant medical microbiologist; Elizabeth Gibbs, patient representative; Kate Gould, consultant microbiologist (clinical adviser to the group); Helen Jenkinson, hygiene code implementation manager; Kathryn Kitson, team leader for orthopaedic and trauma theatres (until December 2007); David Leaper, chair of the group, consultant surgeon and professor, wound healing; Matt Thompson, consultant surgeon and professor, vascular surgery; Jennie Wilson, infection control nurse and programme leader, surgical site infection surveillance service; and the following staff members of the National Collaborating Centre for Women’s and Children’s Health: Shona Burman-Roy, systematic reviewer; Katherine Cullen, health economist; Eva Gautam-Aitken, project manager; Paul Jacklin, senior health economist; Ana Palanca, research assistant; Edmund Peston, document supply coordinator; Roxana Rehman, work programme coordinator; Andrew Welsh, editor; Martin Whittle, clinical co-director; Danielle Worster, information scientist.

    • Contributors: DL, SB-R, and MW wrote the initial draft of the article using material produced collectively by the entire guideline development group. AP, KC, DW, and EG-A contributed to the revision and the final draft of this article. The guarantor is MW.

    • Funding: The National Collaborating Centre for Women’s and Children’s Health was commissioned and funded by the National Institute for Health and Clinical Excellence to write this summary.

    • Competing interests: DL is a part time medical adviser to Renovo on trials of antiscarring agents, and he has a small number of shares in the company. Previously, DL has advised Arizant and Inditherm, which make warming products. He also advises Hutchinson on the development and evaluation of a new device to measure tissue oxygen. The department of wound healing at Cardiff University, where DL is a visiting professor, has received financial support from a large number of companies who have developed products in this area. DL has had many charitable and industry grants for research work in antibiotic prophylaxis and treatment, dressings, and tissue perfusion. He has received financial support from several companies to attend and give papers to meetings of international societies and for educational activities; most of this funding related to the Surgical Infection Society and the European Wound Management Association (previously president) and the European Tissue Repair Society (current board member).

    • Provenance and peer review: Commissioned; not externally peer reviewed.

    References