What preoperative measures should be taken for a patient undergoing rectal surgery who is negative for Methicillin-resistant Staphylococcus aureus (MRSA) to prevent surgical site infections?

Preoperative Measures for MRSA-Negative Patients Undergoing Rectal Surgery

For a patient who is MRSA-negative undergoing rectal surgery, apply antiseptic skin preparation with chlorhexidine-alcohol solution immediately before surgery and use clippers (not razors) for hair removal only if necessary on the day of surgery. 1

Skin Antiseptic Preparation

Sterile preparation of the operative site with an effective antiseptic is the cornerstone of preventing surgical site infections. 2

• Use chlorhexidine-alcohol solution for skin preparation, which is superior to povidone-iodine in preventing surgical site infections. 1, 3
• Specifically, 2.0-2.5% chlorhexidine in alcohol significantly reduces surgical site infection rates compared to aqueous iodine solutions (relative risk 0.75). 3
• The combination formulation of povidone-iodine and alcohol is similar or superior to povidone-iodine aqueous solution and delivers effective antimicrobial activity with only a 30-second application if chlorhexidine is not available. 2
• Traditional skin scrubbing prior to antiseptic application provides no additional benefit—painting with antiseptic alone is sufficient. 2

Hair Removal

Avoid routine hair removal entirely; if hair removal is deemed necessary, use clippers immediately before surgery rather than razors. 2, 1

• Randomized controlled trials demonstrate no difference in surgical site infection rates between patients who had hair removed and those who did not. 2
• When hair removal is performed, clipping and depilatory creams result in fewer surgical site infections than shaving with a razor. 2
• There is no difference in infection rates whether hair is removed the day before surgery versus the day of surgery. 2

What NOT to Do for MRSA-Negative Patients

Nasal decolonization with mupirocin is NOT indicated for MRSA-negative patients. 4

• Mupirocin decolonization protocols (intranasal mupirocin 2% twice daily for 5 days combined with chlorhexidine body wash) are specifically reserved for MRSA-colonized patients undergoing high-risk procedures like orthopedic surgery. 4
• Since this patient is MRSA-negative, decolonization protocols are unnecessary and would represent inappropriate antimicrobial use.

Additional Preoperative Considerations

Preoperative bathing with antiseptic solutions provides no proven benefit over regular soap and water. 2, 5

• A Cochrane review of six randomized controlled trials involving 10,007 patients found that preoperative bathing with antiseptic preparations provided no benefit in reducing surgical site infections compared to non-antiseptic preparations. 2, 5

For rectal surgery specifically, consider bowel preparation protocols. 1

• Mechanical bowel preparation alone provides no clinical benefit and should not be used routinely, though it may be considered for rectal surgery particularly when a diverting stoma is planned. 1
• If mechanical bowel preparation is used, add oral antibiotics (such as neomycin plus erythromycin or metronidazole), as the combination significantly reduces surgical site infections compared to mechanical bowel preparation with systemic antibiotics alone. 1

Common Pitfalls to Avoid

• Do not shave the surgical site with razors—this increases surgical site infection risk compared to clipping or no hair removal. 2, 1
• Do not perform hair removal weeks before surgery—if needed, it should be done immediately before the procedure. 2
• Do not use mupirocin or other decolonization protocols in MRSA-negative patients—these are reserved for documented MRSA carriers. 4
• Do not rely on preoperative antiseptic bathing alone—evidence shows no benefit over regular bathing. 2, 5