GUIDE TO INFECTION

CONTROL IN THE HEALTHCARE

SETTING

Preparing the Patient for

Surgery
Authors
Helen Giamarellou, MD, PhD
Anastasia Antoniadou MD, PhD

Chapter Editor
Victor D. Rosenthal, MD, CIC, MSc

Topic Outline
Key Issues
Known Facts
Controversial Issues
Definitions
Suggested Practice
Patient Preparation for Surgery
Surgical Site Preparation and Care
Suggested Practice in Antimicrobial Prophylaxis
Suggested Practice in Under-Resourced Settings
Summary
References

Chapter last updated: April 2018

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KEY ISSUE

• Surgical site infections (SSIs) are preventable and epidemiologically

important, affecting up to one third of patients who had surgery in low-
and middle-income countries1-8 and being the second most common
healthcare-associated infection in Europe and the USA. Prevention
requires measures before, during, and after surgery.
• Appropriate organ function support, skin preparation, antimicrobial
prophylaxis and wound care, decrease the incidence of both incisional
and deep infections (organ or space) after certain operations.

KNOWN FACTS

New guidelines have been issued by WHO (2016) and CDC (2017).
Decreasing the risk of SSIs and strongly recommended are: a preoperative
shower, decolonization of patients with known nasal carriage of
Staphylococcus aureus (especially in cardiothoracic and orthopaedic
surgery), avoiding hair removal or, if this is absolutely necessary, removal
with a clipper, surgical site skin preparation with alcohol-based antiseptics
in the operating room, a single preoperative dose of a first- or second-
generation cephalosporin within 120 minutes before incision (considering
the half-time of the antibiotic) and intraoperative organ support with
normothermia, hyperoxygenation, and intensive blood glucose control
(<200 mg/dl). Regrettably, more than one postoperative doses of
prophylaxis are generally administered in several medical centers leading
to excess cost and the emergence of multiresistant bacteria.

Controversial Issues

• Assessment of risk factors in clean and laparoscopic operations requires

more studies.

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• Weight-based dosing for antimicrobial prophylaxis in obese patients
must be clarified.
• The protocols for screening for nasal S. aureus carriage before surgery
and decolonization with mupirocin must be precisely defined.
• Rectal screening for extended-spectrum beta-lactamases (ESBL) or
other multidrug-resistant (MDR) pathogens according to risk factors and
the impact to SSI incidence and outcome should be clarified.

DEFINITIONS

• SSIs are infections of the surgical site incision or organ or space,

occurring after surgery. The superficial (incisional) infections involve only
the skin and subcutaneous tissues while deep (organ or space)
infections involve at least muscle and fascial layers. Incisions may be
contaminated by the patient’s own normal flora or by flora from the
environment, including the operative team. Correct surveillance of SSIs
extends to 30 days following surgery. In the case of implants,
surveillance is extended from 90 days (USA) for up to 1 year (Europe,
ECDC).
• The surgical wound classification system was established based on the
exposure of the incision to bacterial contamination (see Table 39.1).
Infection was reported in 3.3% of clean wounds, in 10.8% of clean-
contaminated, in 16.3% of contaminated, and in 28.6% of dirty wounds.
The risk for SSI is multifactorial, including patient status and
comorbidities, clinical practice, surgery, and wound class characteristics.
Efforts for indexes to estimate the patient’s risk for SSI have been made,
for example the NNIS (Nosocomial Infections Surveillance System) risk
index which includes 3 factors: (a) a contaminated or dirty wound class
(1 point); (b) a high preoperative risk as defined by the American Society
of Anesthesiologists (ASA) preoperative assessment score (see Table
39.2) of 3 or more (1 point); and (3) duration of operation exceeding the
75th percentile for a given procedure (1 point). With zero points the risk
for SSI is estimated to be 1.5% and for a sum of 3 points 13%.
Malnutrition, advanced age, increased patient dependence, obesity,
diabetes mellitus, renal insufficiency, cirrhosis, coexisting remote body-
site infections, recent surgical procedure, increased length of
preoperative hospitalization, known colonization with methicillin-resistant

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 S. aureus (MRSA) or vancomycin-resistant enterococci (VRE),
placement of foreign bodies, malignancy, and the use of steroids or
immunosuppressive drugs represent additional risk factors for SSI, as
evident by systematic reviews.
• The heavy burden of SSI in low and middle-income countries.1-8 is
illustrated in findings of a cohort, prospective, multicenter surveillance
study on SSIs conducted by the International Nosocomial Infection
Control Consortium (INICC) in 82 hospitals of 66 cities in 30 countries
(Argentina, Brazil, Colombia, Cuba, Dominican Republic, Egypt, Greece,
India, Kosovo, Lebanon, Lithuania, Macedonia, Malaysia, Mexico,
Morocco, Pakistan, Panama, Peru, Philippines, Poland, Salvador, Saudi
Arabia, Serbia, Singapore, Slovakia, Sudan, Thailand, Turkey, Uruguay,
and Vietnam). SSI rates were significantly higher for most types of
surgical procedures analyzed in INICC hospitals compared with CDC-
NHSN (National Healthcare Safety Network) data, including the rates of
SSI after hip prosthesis (2.6% vs. 1.3%; relative risk [RR], 2.06 [95%
confidence interval (CI), 1.8-2.4]; P <.001), coronary bypass with chest
and donor incision (4.5% vs. 2.9%; RR, 1.52 [95% CI, 1.4-1.6]; [P
<.001); abdominal hysterectomy (2.7% vs. 1.6%; RR, 1.66 [95% CI, 1.4-
2.0]; P <.001); exploratory abdominal surgery (4.1% vs. 2.0%; RR, 2.05
[95% CI, 1.6-2.6]; P <.001); ventricular shunt, 12.9% vs. 5.6% (RR, 2.3
[95% CI, 1.9-2.6]; P <.001, among others.8

SUGGESTED PRACTICE

General Principles

Patient Preparation for Surgery

Preparation of patients for surgery aiming at preventing postoperative SSI

is based on appropriate skin care, and antimicrobial prophylaxis. Additional
recommended measures are:
• Appropriate treatment of remote infections before elective operations.
• Intensive control of blood glycose levels(<200 mg/dl or even <180 mg/dl)
perioperatively both in diabetics and not diabetics.

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• Perioperative oxygenation in adult patients undergoing general
anaesthesia with endotracheal intubation for surgical procedures, who
should receive an 80% fraction of inspired oxygen (FiO2)
intraoperatively and, if feasible, in the immediate postoperative period
for 2-6 h.
• Maintenance of normothermia in the operating room either by the use of
warming devices or blankets.
• Decolonization of known nasal carriage of S. aureus especially in
orthopaedic and cardiothoracic surgery with intranasal 2% mupirocin
ointment for 5 days, with or without a combination of a chlorhexidine
body wash.
• Mechanical bowel preparation in colorectal procedures, combined with
oral neomycin sulfate plus erythromycin base or metronidazole, which
should be given the day prior to surgery, in addition to preoperative IV
antimicrobial prophylaxis. Mechanical bowel preparation should not be
used alone.

Surgical Site Preparation and Care

Decontamination of the skin preoperatively is very important to prevent

wound infection, particularly in clean procedures. A shower before surgery
with an antimicrobial or plain soap is recommended. Hair removal at the
operative site is discouraged since existing evidence shows that patients
with no hair removal may have even lower rates of SSIs; when considered
absolutely necessary it must be done with clippers preferably before
operation. Skin preparation in the operating room at the surgical site should
be performed by trained personnel using an alcohol-based antiseptic
solution based on chlorhexidine gluconate. Antimicrobial skin sealants after
skin preparation, or plastic adhesive incise drapes should not be used.
Sterile drapes, non-woven disposable or woven reusable are suggested.
Triclosan-coated sutures are suggested to be used in all types of surgery.
Irrigation of incision with antibiotics before closure must be avoided as also

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the use of advanced dressings (e.g., silver impregnated) since they provide
no benefit compared to standard dressings. If resources are permissive,
prophylactic negative-pressure wound therapy is suggested in high-risk
wounds (e.g., poor tissue perfusion, bleeding or hematoma, dead space,
intraoperative contamination). Antimicrobial agents (e.g., ointments,
solutions, or powders) should not be applied to the surgical incision for the
prevention of SSIs. Laminal air flow ventilation systems for patients
undergoing total arthroplasty should not be used.

Suggested Practice in Antimicrobial Prophylaxis

• A single, full therapeutic dose of an antibiotic should be given

intravenously within 120 minutes before surgical incision (30-120
minutes considering the half-life of the antibiotic) to ensure effective
tissue concentrations throughout the operative period. Prophylaxis
should not be extended beyond 24 hours following surgery. An
exception to this rule is cardiac surgery where prolongation of
antimicrobial prophylaxis for 24-48 hours seems to be beneficial.
Antibiotics are effective when given before inoculation of bacteria at the
surgical site, whereas they are ineffective if given 3 to 4 hours after the
surgical incision. Continuing prophylaxis until all indwelling drains and
intravascular catheters are removed is strongly discouraged. As long as
adequate serum and tissue drug levels against probable pathogens are
maintained during the operation, a single dose is as effective as multiple
doses. Current limited evidence does not support a modification in
dosing for obese patients.
• The selection of the appropriate drug should be based on the bacteria
most likely to cause infection in each situation, its safety profile, as well
as the local resistance surveillance patterns. A single drug should be
used, whenever possible. Cephalosporins, particularly and particularly
cefazolin is ideal for prophylaxis because of its broad spectrum of
activity, the moderately long serum half-life, low toxicity, ease of

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 administration, and low cost. In clean-contaminated cases without entry
into the gastrointestinal tract and in clean operations involving the
surgical placement of foreign material (e.g., heart valves, vascular
grafts, orthopedic hardware, etc.), or whenever risk factors for SSI
coexist, cefazolin alone should be administered. In clean contaminated
operations with entry into the gastrointestinal tract as well as in
penetrating abdominal trauma or primary appendectomy, cefazolin plus
an agent active against anaerobes like metronidazole as well as
cefotetan or cefoxitin as single agents, should be used. Administration of
antibiotics in contaminated and dirty operations is considered therapy
and not prophylaxis. Third-generation cephalosporins are more costly
and promote the emergence of resistant strains. In general, they should
not be used routinely for prophylaxis.
• In colorectal surgery and in institutions where there is increasing
resistance to first and second generation cephalosporins among Gram-
negative isolates from SSIs, ceftriaxone plus metronidazole should be
preferred over ertapenem. For patients with beta-lactam allergies,
metronidazole or clindamycin plus an aminoglycoside or a
fluoroquinolone or aztreonam could replace as above the suggested
regimens.
• Since staphylococci are the major threat in infected prostheses,
vancomycin instead of cefazolin should be used in institutions with a
high predominance of methicillin-resistant strains (>15-20%) as well as
in beta-lactam allergic patients. Because of prolonged infusion time
required for vancomycin (1h) it should be administered within 120 min
before surgical incision.
• In the case of excessive blood loss (>1,5 Lt), or whenever the duration
of operation exceeds 2 half-lives of the preadministered antibiotic(s),
intraoperative redosing should be given. The redosing interval should be
measured from the time of administration of the preoperative dose, not
from the beginning of the procedure.

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• In laparoscopic biliary tract procedures since some factors increasing
the risk for SSI cannot be determined before the procedure (e.g.,
gallbladder empyema, perforation or infection, prolongation of procedure
>60 minutes), it may be reasonable to give a single dose of antimicrobial
prophylaxis to all patients.
• With the exception of ophthalmic procedures, topical administration of
antibiotics as prophylaxis, based on their lack of efficacy and the
possibility of adverse reactions, is not recommended.

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SUGGESTED PRACTICE IN UNDER-RESOURCED SETTINGS

• In 2016 WHO issued Global guidelines for the prevention of surgical site
infection with a panel of experts from all 6 WHO regions. These
guidelines for the pre-, intra- , and postoperative patient care were
elaborated according to the best available scientific evidence and expert
consensus, with the aim to ensure high-quality care for every patient,
irrespective of the resources available (http://www.who.int/gpsc/ssi-
guidelines/en/). Recommendations rated as “strong” in these guidelines
are considered to be adaptable for implementation in most (if not all)
situations, and patients should receive the intervention as the course of
action. For “conditional” recommendations, a more structured decision-
making process should be undertaken, considering stakeholder
consultation, availability of resources, patients’ and healthcare
professionals’ preferences. Most of the recommendations presented
above are included in those “strongly” recommended by WHO

SUMMARY

There is no doubt that appropriate antibiotic prophylaxis along with patient

and surgical site preparation reduce morbidity and costs by preventing
surgical site infections. However, it should be emphasized that antibiotic
overuse and misuse for surgical prophylaxis accounts for as many as half
of all antibiotics costs prescribed in U.S. hospitals and contributes to the
emergence of multidrug-resistant microorganisms particularly whenever the
one single preoperative dose is exceeded. Based on the importance of the
application of correct perioperative antibiotic prophylaxis as well as the
appropriate preparation of patients for surgery, it has been recently
suggested that hospitals should establish a multidisciplinary team including
surgeons, anaesthesiologists, nurses, pharmacists, infection control

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specialists, and clinical microbiologists, who should develop and implement
a relevant bundle protocol.

Table 39.1 Classification of Surgical Wounds

Clean
Elective, not emergency
No entry into the gastrointestinal, respiratory, genital or uninfected urinary
tracts
No signs of acute inflammation or infection
Non-traumatic
No violations of aseptic technique
Non-penetrating trauma
Wounds primarily closed and drained (if necessary) with closed drainage
Clean-Contaminated
Urgent or emergency case that is otherwise clean
Entry into the gastrointestinal, respiratory, genital or urinary tract under
controlled conditions and without significant contamination
Biliary tract, oropharynx, vagina and appendix included if no evidence of
infection is present
No major break in aseptic technique is encountered
Contaminated
Non-purulent inflammation
Major contamination following entry into the gastrointestinal or respiratory
tracts
Entrance of genitourinary or biliary tracts in the presence of acute infection
Fresh traumatic wounds(<4 hours old)
Chronic open wounds to be grafted or covered
Major break in aseptic technique
Dirty
Penetrating trauma >4 hours old
Acute bacterial inflammation or pus encountered
Perforated viscus encountered

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Traumatic wound with retained devitalized tissue, foreign material, fecal
contamination, and/or delayed treatment

Table 39.2 ASA Physical status (PS) classification system

ASA PS Examples, including, but not limited

Definition
Classification to:

ASA I A normal Healthy, non-smoking, no or minimal

healthy patient alcohol use

ASA II A patient with Mild diseases only without substantive

mild systemic functional limitations. Examples include
disease (but not limited to): current smoker,
social alcohol drinker, pregnancy,
obesity (30 < BMI < 40), well-controlled
DM/HTN, mild lung disease

ASA III A patient with Substantive functional limitations; One

severe or more moderate to severe diseases.
systemic Examples include (but not limited to):
disease poorly controlled DM or HTN, COPD,
morbid obesity (BMI ≥40), active
hepatitis, alcohol dependence or abuse,
implanted pacemaker, moderate
reduction of ejection fraction, ESRD
undergoing regularly scheduled
dialysis, premature infant PCA <60
weeks, history (>3 months) of MI, CVA,
TIA, or CAD/stents.

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ASA IV A patient with Examples include (but not limited to):
severe recent (< 3 months) MI, CVA, TIA, or
systemic CAD/stents, ongoing cardiac ischemia
disease that is or severe valve dysfunction, severe
a constant reduction of ejection fraction, sepsis,
threat to life DIC, ARD, or ESRD not undergoing
regularly scheduled dialysis

ASA V A moribund Examples include (but not limited to):

patient who is ruptured abdominal/thoracic aneurysm,
not expected to massive trauma, intracranial bleed with
survive without mass effect, ischemic bowel in the face
the operation of significant cardiac pathology or
multiple organ/system dysfunction

ASA VI A declared
brain-dead
patient whose
organs are
being removed
for donor
purposes

BMI: Body Mass Index; DM: Diabetes Mellitus; HTN: Hypertension; COPD:
Chronic Obstructive Pulmonary Disease; ESRD: End Stage Renal Disease;
PCA: Patient-Controlled Analgesia; MI: Myocardial Infarction; CVA:
Cerebrovascular Accident; TIA: Transient Ischaemic Attack; CAD:
Coronary Artery Disease; DIC: Disseminated Intravascular Coagulation;
ARD: Acute Respiratory Distress

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REFERENCES

1. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical Practice

Guidelines for Antimicrobial Prophylaxis in Surgery. Am J Health-Syst
Pharm 2013; 70(3): 195–83. doi: 10.2146/ajhp120568.
2. Classen DC, Evans RS, Restomic SL, et al. The timing of
prophylactic administration of antibiotics and the risk of surgical
wound infection. N Engl J Med 1992; 326(5):281–6.
3. European Center for Disease Prevention and Control Technical
Report: Systemic Review and Evidence-Based Guidance on
Perioperative Antibiotic Prophylaxis. Stockholm: ECDC; 2013
Catalogue number TQ-01-13-279-EN-C.
4. Korol E, Johnston K, Waser N, et al. A Systematic Review of Risk
Factors Associated with Surgical Site Infections among Surgical
Patients. PloS One 2013; 8(12):1–9. doi:
10.1371/journal.pone.0083743.
5. Allegranzi B, Bischoff P, de Jonge S, et al. New WHO
Recommendations on Preoperative Measures for Surgical Site
Infection Prevention: An Evidence-Based Global Perspective. Lancet
Infect Dis 2016; 16(12):e276–87. doi: 10.1016/S1473-
3099(16)30398-X.
6. Allegranzi B, Zayed B, Bischoff P, et al. New WHO
Recommendations on Intraoperative and Postoperative Measures for
Surgical Site Infection Prevention: An Evidence-Based Global
Perspective. Lancet Infect Dis 2016; 16(12):30402–9.
7. Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for
Disease Control and Prevention Guideline for the Prevention of
Surgical Site Infection, 2017. JAMA Surg 2017; 152(8):784–91. doi:
10.1001/jamasurg.2017.0904.

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SUGGESTED REFERENCES IN UNDER-RESOURCED
SETTINGS

1. Viet Hung N, Anh Thu T, Rosenthal VD, et al. Surgical Site Infection
Rates in Seven Cities in Vietnam: Findings of the International
Nosocomial Infection Control Consortium. Surg Infect (Larchmt). 2016;
17(2):243–9. doi: 10.1089/sur.2015.073.
2. Richtmann R, Siliprandi EM, Rosenthal VD, et al. Surgical Site Infection
Rates in Four Cities in Brazil: Findings of the International Nosocomial
Infection Control Consortium. Surg Infect (Larchmt) 2016; 17(1):53–7.
doi: 10.1089/sur.2015.074.
3. Singh S, Chakravarthy M, Rosenthal VD, et al. Surgical Site Infection
Rates in Six Cities of India: Findings of the International Nosocomial
Infection Control Consortium (INICC). Int Health 2015; 7(5):354–9. doi:
10.1093/inthealth/ihu089.
4. Ramirez-Wong FM, Atencio-Espinoza T, Rosenthal VD, et al. Surgical
Site Infections Rates in More Than 13,000 Surgical Procedures in Three
Cities in Peru: Findings of the International Nosocomial Infection Control
Consortium. Surg Infect (Larchmt) 2015. 16(5):572–6. doi:
10.1089/sur.2014.201.
5. Leblebicioglu H, Erben N, Rosenthal VD, et al. Surgical Site Infection
Rates in 16 Cities in Turkey: Findings of the International Nosocomial
Infection Control Consortium (INICC). Am J Infect Control 2015;
43(1):48–52. doi: 10.1016/j.ajic.2014.09.017.
6. Portillo-Gallo JH, Miranda-Novales MG, Rosenthal VD, et al. Surgical
Site Infection Rates in Four Mexican Cities: Findings of the International
Nosocomial Infection Control Consortium (INICC). J Infect Public Health
2014; 7(6):465–71. doi: 10.1016/j.jiph.2014.07.015
7. Alvarez-Moreno C, Perez-Fernandez AM, Rosenthal VD, et al. Surgical
Site Infection Rates in 4 Cities in Colombia: Findings of the International

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 Nosocomial Infection Control Consortium (INICC). Am J Infect Control.
2014; 42(10):1089–92. doi: 10.1016/j.ajic.2014.06.010.
8. Rosenthal VD, Richtmann R, Singh S, et al. Surgical Site Infections,
International Nosocomial Infection Control Consortium (INICC) Report,
Data Summary of 30 Countries, 2005-2010. Infect Control Hosp
Epidemiol 2013; 34(6): 597–604.

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