Surgical Site Infection Prevention and Treatment
Prevention Strategy
Implement a comprehensive bundle of evidence-based interventions spanning preoperative, intraoperative, and postoperative phases to reduce surgical site infection rates and associated morbidity.
Preoperative Measures
Antibiotic Prophylaxis:
- Administer cefazolin 1-2 grams IV within 30-60 minutes before surgical incision to ensure adequate tissue levels at the time of initial incision 1
- For lengthy procedures (≥2 hours), redose with 500 mg to 1 gram intraoperatively based on the antibiotic's half-life 1
- Continue prophylaxis for 24 hours postoperatively in most cases; extend to 3-5 days only for procedures where infection would be devastating (open-heart surgery, prosthetic arthroplasty) 1
Skin Preparation:
- Use preoperative skin antiseptics for all clean surgeries 2
- Perform hair removal only if necessary, using electric clippers in the operating room immediately before surgery—never razors 2
- For cesarean sections, apply vaginal preparation with antiseptic solution 2
Patient Optimization:
- Screen for and decontaminate Staphylococcus aureus nasal carriers preoperatively 2
- Address modifiable risk factors including smoking cessation, glycemic control in diabetics, and nutritional optimization 3
- Avoid routine perineal shaving on admission for labor 2
Intraoperative Measures
Surgical Technique:
- Use triclosan-coated sutures, which significantly reduce SSI prevalence compared to non-coated sutures 2
- Apply dual-ring wound protectors rather than single-ring devices, as they demonstrate superior SSI prevention 2
- Maintain intraoperative normothermia using active warming devices to decrease SSI rates 2
Avoid Ineffective Interventions:
- Do not use perioperative supplemental oxygenation specifically for SSI prevention, as it does not reduce infection rates 2
Wound Management:
- Consider delayed primary skin closure for highly contaminated or "dirty" abdominal operations in high-risk patients, though evidence is not definitive 2
- Apply negative-pressure wound therapy (NPWT) prophylactically in high-risk patients, which reduces SSI by 58% and wound dehiscence by 29% 4
Postoperative Measures
Wound Care:
- Use appropriate dressings for surgical incisions 2
- Consider water quality and wound type (primary vs. secondary closure) when planning early versus delayed bathing 2
- Implement hand hygiene protocols before wound manipulation 2
High-Risk Wound Management:
- For large wounds or those at high dehiscence risk, apply NPWT 4
- In contaminated wounds requiring delayed closure, combine NPWT with delayed closure (reduces SSI from 37% to 0% compared to primary closure) 4
Treatment of Established SSI
Immediate Intervention:
- Open and drain infected wounds immediately when purulent drainage, erythema, or fluctuance is present—this is the cornerstone of SSI treatment 4
- Remove sutures or staples overlying the infected area to allow adequate drainage 4
- Perform wound irrigation and debride necrotic tissue 4
- Pack wounds loosely with saline-moistened gauze and plan for delayed closure or healing by secondary intention 4
Systemic Signs Requiring Escalation:
- Admit patients with fever >38.5°C with tachycardia, hypotension, oliguria, altered mental status, or rapidly spreading erythema 4
- Initiate IV antibiotics and consider surgical debridement for systemic signs or necrotizing infection 4
Advanced Wound Management:
- Apply NPWT for complex cases with large wounds or high dehiscence risk 4
Common Pitfalls to Avoid
- Timing errors: Antibiotic prophylaxis given too early (>60 minutes) or too late (<30 minutes before incision) loses effectiveness 1
- Prolonged prophylaxis: Extending antibiotics beyond 24 hours in routine cases increases resistance without reducing SSI 1
- Inadequate drainage: Attempting to manage purulent SSI with antibiotics alone without surgical drainage leads to treatment failure 4
- Ignoring modifiable factors: Failing to address patient-specific risks (smoking, hyperglycemia, malnutrition) preoperatively 3