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Guideline For Prevention of Surgical Wound Infections, 1985

Julia S. Garner, R.N, M.N. Hospital Infections Program Centers for Infectious Diseases Center for Disease Control

Publication date: 01/01/1982


Table of Contents

RANKING SCHEME FOR RECOMMENDATIONS

PREFACE
References

INTRODUCTION

EPIDEMIOLOGY
Clean Wounds
Clean-Contaminated Wounds
Contaminated Wounds
Dirty or Infected Wounds

CONTROL MEASURES

RECOMMENDATIONS

REFERENCES

POINT OF CONTACT FOR THIS DOCUMENT:


RANKING SCHEME FOR RECOMMENDATIONS

CATEGORY I

Measures in Category I are strongly supported by well-designed and controlled clinical studies that show their effectiveness in reducing the risk of nosocomial infections or are viewed as effective by a majority of expert reviewers. Measures in this category are viewed as applicable for most hospitals -- regardless of size, patient population, or endemic nosocomial infection rates.

CATEGORY II

Measures in Category II are supported by highly suggestive clinical studies in general hospitals or by definitive studies in specialty hospitals that might not be representative of general hospitals. Measures that have not been adequately studied but have a logical or strong theoretical rationale indicating probable effectiveness are included in this category. Category II recommendations are viewed as practical to implement in most hospitals.

CATEGORY III

Measures in Category III have been proposed by some investigators, authorities, or organizations, but, to date, lack supporting data, a strong theoretical rationale, or an indication that the benefits expected from them are cost effective. Thus, they are considered important issues to be studied. They might be considered by some hospitals for implementation, especially if the hospitals have specific nosocomial infection problems, but they are not generally recommended for widespread adoption.


PREFACE

In 1980, the Centers for Disease Control (CDC) began developing a series of guidelines entitled Guidelines for the Prevention and Control of Nosocomial Infections. The purpose of the Guidelines was twofold: 1) to disseminate advice on how to prevent or control specific nosocomial infection problems and 2) to cover the questions most frequently asked of the Hospital Infections Program staff on different aspects of the hospital's inanimate environment (1).

In March 1982, the Guideline for Prevention of Surgical Wounds was published (2), and copies were mailed to all U.S. acute-care hospitals. The Guideline was written by Bryan P. Simmons, M.D. in collaboration with a working group consisting of J. Wesley Alexander, M.D.; N. Joel Ehrenkranz, M.D.; Robert H. Fitzgerald, Jr., M.D.; Allen B. Kaiser, M.D.; William J. Ledger, M.D.; Jonathan k. Meakins, Jr., M.D.; Colonel Darlene F. McLeod, ANC; and Hiram C. Polk. Jr., M.D. (2).

Subsequently, two statements pertinent to the Guideline were issued by CDC. In October 1983, a statement entitled "Clarification of Guideline Recommendations on Generic Antiseptic, Disinfectant, and Other Products" was mailed to all U.S. acute-care hospitals. The statement emphasized that CDC recommendations are not intended to endorse any particular commercial product or to exclude the use of other commercial products containing generic ingredients not mentioned in the Guideline.

In November 1983, a follow-up statement requested that users delete the portion of the Guideline that recommended specific generic antimicrobial ingredients for use in patient preoperative skin preparations, skin antiseptics, and surgical hand scrubs and announced that the entire Guideline would be revised.

In October 1984, a draft of the proposed revision was mailed to 150 scientists and infection control professionals for review and comment. Rather than using an expert working group to finalize the content of this Guideline, we used the written comments and suggestions which we received from the 150 scientists and infection control professionals to determine the final content of the Guideline and the ranking of the recommendations.

This Guideline incorporates the above revisions, as well as newly available information. The major changes from the original Guideline are listed below:

  1. Rather than recommending specific generic antimicrobial ingredients for skin antiseptics, patient preoperative skin preparations, and surgical hand scrubs, the Guideline indicates that hospitals may choose from appropriate products in categories defined by the U.S. Food and Drug Administration (FDA), since preparations used to inhibit or kill microorganisms on skin are categorized by an FDA advisory review panel for nonprescription (over the-counter {OTC}) antimicrobial drug products (3). Manufacturers of antimicrobial-containing products voluntarily submit data to the review panel, which categorizes the products according to their intended use, i.e., patient preoperative skin preparations, skin antiseptics, skin wound cleansers, skin wound protectants, surgical hand scrubs, health care personnel hand washes, and antimicrobial soaps. Generic antimicrobial for each use category are further divided: Category I (safe and efficacious); Category II (not safe and/or efficacious); and Category III (insufficient data to categorize). Consequently, chemical germicides formulated as antiseptics are categorized by the FDA into groupings by use and efficacy, but they are not regulated or registered in the same fashion as chemical germicides are by the U.S. Environmental Protection Agency.

    Persons responsible for selecting commercially marketed skin antiseptics, antimicrobial preoperative skin preparations, and antimicrobial surgical hand scrubs can obtain information about categorization of products from the Center for Drugs and Biologics, Division of OTC Drug Evaluation, FDA, 5600 Fishers Lane, Rockville, Maryland 20857. In addition, information published in the scientific literature, presented at scientific meetings, documented by manufacturers, and obtained from other sources deemed important may be considered.
  2. Recommendations for preoperative removal of patient hair have been modified to emphasize clipping rather than shaving if hair removal is necessary.
  3. Recommendations for operating room ventilation have been revised to a minimum of 20 air changes per hour rather than 25 air changes, to be consistent with new guidelines from the Health Resources and Services Administration, Public Health Service, U.S. Department of Health and Human Services (4).

The recommendations presented in this Guideline were chosen primarily for their acknowledged importance to infection control, but other factors, such as the feasibility of implementing them and their potential costs to hospitals, were also considered. Many recommendations are intended to reduce or eliminate expensive practices in the operating room that are not likely to prevent infections. Some of the recommendations are based on well-documented epidemiologic studies; others are based on a reasonable theoretical rationale, since for many of these practices little or no scientifically valid evidence is available to permit evaluation of their effect on the incidence of infection. Because new studies are constantly providing pertinent information in this field, users of this Guideline should keep informed of data from scientific meetings, biomedical journals, government publications, accreditation standards, hospital and health-care associations, and manufacturers. The recommendations presented in this Guideline may be modified as necessary for an individual hospital and are not meant to restrict a hospital from developing recommendations that may be more appropriate to its own unique needs. The recommendations have no force of law or regulation.

References

  1. Haley RW. CDC guidelines on infection control. Infect Control 1981:2: 1-2.
  2. Simmons BP. Guideline for prevention of surgical infections. Infect Control 1982;3(Suppl):188-96.
  3. Zanowiak P, Jacobs MR. 1982. Topical anti-infective products. In: Handbook of Non-Prescription Drugs, 7th Edition. pp 525-542. American Pharmaceutical Association, Washington, D.C.
  4. U.S. Department of Health and Human Services. Guideline for construction and equipment of hospital and medical facilities. Washington: Government Printing Office. July, 1984. (DHHS publication no. (HR5-M-HF) 84-1).

INTRODUCTION

Surgical wound infections are the second most frequent nosocomial infection in most hospitals and are an important cause of morbidity, mortality, and excess hospital costs (1-4). They are divided into infections 1) confined to the incisional wound and 2) involving structures adjacent to the wound that were entered or exposed during an operation (sometimes called "deep infections"). Some 60%-80% of infections are incisional, and the rest are at adjacent sites, for example, intraabdominal/retroperitoneal and deep soft tissue (5,6). This Guideline deals primarily with incisional infections, although many recommendations in it will also help prevent infections at adjacent sites. Burn wounds are not discussed.


EPIDEMIOLOGY

In general, a wound can be considered infected if purulent material drains from it, even without the confirmation of a positive culture(7). This clinical definition has advantages compared with those based on culture results, because 1) a positive culture does not necessarily indicate infection, since many wounds, infected or not, are colonized by bacteria, and 2) infected wounds may not yield pathogens by culture because some pathogens are fastidious, culture techniques are inadequate, or the patient has received antimicrobial therapy. On the other hand, infections, for example, those in the granulocytopenic patient, may not always produce purulent material. It is therefore also useful to consider a wound infected if the attending surgeon believes it to be. Unless the incision is involved, stitch abscesses should not be counted as surgical wound infections; they can be counted as skin or cutaneous infections.

Wounds can be classified according to the likelihood and degree of wound contamination at the time of operation. A widely accepted classification scheme (7-9) is listed below:

Clean Wounds

These are uninfected operative wounds in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tracts are not entered. In addition, clean wounds are primarily closed, and if necessary, drained with closed drainage. Operative incisional wounds that follow nonpenetrating (blunt) trauma should be included in this category if they meet the criteria.

Clean-Contaminated Wounds

These are operative wounds in which the respiratory, alimentary, genital, or urinary tract is entered under controlled conditions and without unusual contamination. Specifically, operations involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection or major break in technique is encountered.

Contaminated Wounds

These include open, fresh, accidental wounds, operations with major breaks in sterile technique or gross spillage from the gastrointestinal tract, and incisions in which acute, nonpurulent inflammation is encountered.

Dirty or Infected Wounds

These include old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the operative field before the operation.

This classification scheme has been shown in numerous studies to predict the relative probability that a wound will become infected. Clean wounds have a 1%-5% risk of infection; clean-contaminated, 3%-11%; contaminated, 10%-17%; and dirty, over 27% (2,3,7). These infection rates were affected by many appropriate prevention measures taken during the studies, such as use of prophylactic antimicrobials, and would have been higher if no prevention measures had been taken. In addition to the scheme's application to predicting the probability of infection, this classification has other uses. For a given operation, the clean-wound infection rate, in particular, can be used by surgeons to compare their own infection rates, and by inference, their operating techniques, with those of other surgeons (2,10). The classification also can alert personnel to wounds at high risk of infection and thus enable personnel to take appropriate perioperative preventive measures (3,11).

Although the degree or operative contamination of wounds is important in determining the risk of infection, so are host and local wound factors. The host factors leading to increased risk may include very young or old age, presence of a perioperative infection, and possibly diabetes and severe malnutrition (7). Local wound factors associated with high risk include presence of devitalized tissue or foreign bodies and poor blood supply to the wound.

A multivariate index combining patient susceptibility and wound contamination was developed and tested during the CDC Study on the Efficacy of Nosocomial Infection Control (SENIC)(12). This index, which involved 4 risk factors, predicted the surgical wound infection risk about twice as well as the traditional wound classification system. The 4 risk factors were: having an abdominal operation, having an operation that lasted longer than 2 hours, having a contaminated, dirty, or infected operation by the traditional classification system, and having 3 or more discharge diagnoses. Since this index includes discharge diagnoses, some modification and a prospective evaluation of the index are needed before it can be recommended for adoption.

Surgical wound infections are most often localized to the wound and with appropriate treatment usually do not result in major complications. Local complications include destruction of tissue, wound dehiscence, incisional and deep hernias, septic thrombophlebitis, recurrent pain, and disfiguring and disabling scars. The numerous potential systemic complications include fever, increased metabolic demands that sometimes result in malnutrition, toxemia, bacteremia, shock, metastatic infection, failure of vital organs remote from the infection, and death. The severity of each complication depends in large part on the infecting pathogen and on the site of infection. For example, viridans group streptococci are unlikely to cause a severe infection unless they invade the vascular system, but a group A streptococcal infection is likely to be severe regardless of the site. Further, any infection involving an implanted foreign body or substantial necrotic tissue is likely to have serious sequelae, regardless of the pathogen involved.

As determined by reports to the National Nosocomial Infection Study, gram-negative aerobic bacteria make up approximately 40% of pathogens isolated from surgical wounds. However, Staphylococcus aureus remains the single most frequently isolated species (3). Pathogens other than bacteria, for example, fungi and viruses, are uncommonly reported.

Pathogens that infect surgical wounds can be acquired from the patient, the hospital environment, or personnel. The patient's own flora appears to be responsible for most infections, especially if clean-wound infections are excluded (8). Sources of contamination include the gastrointestinal, respiratory, genital, and urinary tracts and the skin and anterior nares.

Exogenous contamination appears responsible for a substantial proportion of infections of clean wounds. During epidemic periods, exogenous contamination may be responsible for many more infections (14,15). Exogenous contamination may come from any personnel or environmental source, although direct contact with the wound by the surgical team is probably the final pathway for spread of most such contamination. Epidemics of infections due to group A streptococci and some outbreaks of S. aureus wound infections indicate that personnel carriers can be a source. Epidemics due to gram-negative microorganisms may be spread from environmental sources, especially those containing water (for example, irrigating solutions). Most infections, endogenous or exogenous, appear to result from contamination acquired in the operating room. Few infections are acquired after the operation if wounds are closed primarily, that is, before leaving the operating room, and if drains are not used, probably because the normal healing process seals most wounds within 24 hours after closure.


CONTROL MEASURES

The risk of developing a surgical wound infection is largely determined by 3 factors: 1) the amount and type of microbial contamination of the wound, 2) the condition of the wound at the end of the operation (largely determined by surgical technique and disease processes encountered during the operation), and 3) host susceptibility, that is, the patient's intrinsic ability to deal with microbial contamination. These factors interact in a complex manner. For example, a wound in healthy tissue is surprisingly resistant to infection even when contaminated with many microorganisms, but a wound containing foreign or necrotic material is highly susceptible to infection even if few microorganisms are present. Measures intended to prevent surgical wound infections are directed at all 3 factors just mentioned. Since most infections are acquired in the operating room and good surgical practices are crucial to their prevention, most prevention measures should be directed at influencing the practices of the surgical team.

Measures aimed at preventing microbial contamination of the wound begin before the operation. One important preoperative and postoperative measure is the treatment of active infections. A patient who has an active bacterial infection, even if it is at a site remote from the surgical wound, has a greater risk of wound infection than does an uninfected patient (7). Treating a "remote" infection that is present before or after an operation is believed to reduce the risk of wound infection.

Other preoperative measures involving the patient are keeping the preoperative hospital stay short, avoiding hair removal or, if necessary, removing hair with clippers or depilatories rather than a razor, and preparing the operative site with an antiseptic. A short preoperative stay has been associated with low wound infection rates (2,5,7,16). Bathing by the patient with antimicrobial-containing products has been suggested as an effective preoperative prevention measure, because it reduces colonization with typical wound pathogens such as S. aureus (16). Although such bathing is relatively easy, safe, and inexpensive, it has not been proven to reduce colonization with S. aureus in the host's natural reservoir -- the anterior nares -- or to reduce infection rates.

Hair adjacent to the operative site is often removed to prevent the wound from becoming contaminated with hair during the operation. However, several studies (2,17,18) have suggested that shaving with a razor can injure the skin and increase the risk of infection. Clipping hair, using a depilatory, or no shaving at all has been suggested in place of shaving. Results of 2 studies (2,17)suggest that if shaving is necessary, it be performed immediately before the operation.

The skin at the operative site is thoroughly cleaned to remove superficial flora, soil, and debris before the operation to reduce the risk of contaminating the wound with a patient's skin flora. Immediately before the operation, a preoperative skin preparation is applied to the patient's skin to kill or inhibit more adherent, deep, resident flora. A patient preoperative skin preparation is defined as "a safe, fast-acting, broad-spectrum antimicrobial-containing preparation which significantly reduces the number of microorganisms on intact skin" (19).

The surgical team must also take perioperative measures to prevent microbial contamination of the wound. Contamination from the surgical team may result from direct contact, usually with hands or from shedding from skin or mucous membranes. Transfer of microorganisms from hands to the wound is reduced by scrubbing the hands and wearing sterile gloves. The surgical scrub is designed to kill or remove as many bacteria as possible, including resident bacteria. A surgical scrub preparation is defined as: "a nonirritating antimicrobial-containing preparation that significantly reduces the number of microorganisms on the intact skin. A surgical hand scrub should be broad-spectrum, fast-acting, and persistent." (19) The ideal duration of the surgical scrub is not known, but times as short as 5 minutes appear safe (20,21). Once hands are scrubbed, sterile gloves act as an additional barrier to transfer of microorganisms to the wound. However, bacteria can multiply rapidly under gloves and can contaminate the wound through punctures in gloves, which occur frequently (22); use of surgical hand scrubs before putting on gloves should retard bacterial growth.

Air is also a potential source of microorganisms that can contaminate surgical wounds; its role in wound infections has been demonstrated in certain clean operations (7), such as operations in which a foreign body is implanted. Operating room (OR) air is often contaminated with microorganisms that are usually attached to other airborne particles such as dust, lint, skin squames, or respiratory droplets. Many of these microorganisms are potential pathogens. The number of viable airborne microorganisms for a given amount of OR ventilation is largely proportional to human activity. Greater numbers of airborne microorganisms can be expected with increased numbers of persons, especially if OR doors are being opened and the persons are moving, talking, or have uncovered skin areas. Airborne contamination decreases with 1) decreased numbers and activity of personnel, 2) increased ventilation that dilutes contaminated air with relatively clean filtered or outdoor air, 3) ultraviolet light, which kills microorganisms, and 4) proper use of occlusive clothing, masks, and gloves, which reduce shedding into air. Movement or activity in the OR can be decreased by closing the OR door and by limiting the number of personnel in the OR and adjacent corridors. In addition to limiting unnecessary activity, closing the door will decrease mixing of the OR air with corridor air, which may contain higher counts of bacteria. Limiting personnel movement in the OR and adjacent corridors takes planning. The goal of such planning, often called "traffic control," is to make the OR self-sufficient, or nearly so, once an operation has begun.

To reduce airborne contamination, a ventilation system producing a minimum of 20 changes of highly filtered air per hour is recommended for modern ORs (23). Some hospitals have installed "laminar flow" ventilation units for use in ORs (24), especially for rooms used for orthopedic procedures, because these ventilation units can provide nearly sterile air with minimal air turbulence. Investigators from a British multicenter study recently reported that several factors, including ultraclean air in ORs, systemic prophylactic antimicrobials for patients, and exhaust-ventilated suits for personnel reduced the incidence of deep wound infection after total joint replacement operations (25). An editorial about the study suggested that prophylactic antimicrobials are at least as effective as ultraclean air and exhaust ventilated suits in reducing deep sepsis and that cheaper alternatives such as prophylactic antimicrobials "should be exhausted" before any of the substantially more expensive provisions, such as ultraclean air and exhaust ventilated suits, are considered (26). A follow-up report from the multicenter study that examined the cost implications for the British National Health Service of ultraclean air and other infection control measures for total joint replacement suggested that antimicrobial prophylaxis was more cost effective than an ultraclean air system (27). In addition to the above findings, lower baseline rates of deep wound sepsis have been reported following total hip arthroplasty performed in conventional ORs in U.S. hospitals (28-31) than in hospitals in the British multicenter study (25).

Ultraviolet (UV) irradiation may decrease airborne microorganisms to low levels. Although UV-irradiation of ORs has been shown to result in a small but statistically significant decrease in infections of clean surgical wounds, infections of all surgical wounds combined were not reduced (7). Further, use of UV irradiation in ORs has several distinct disadvantages. UV light requires routine use of a visor or goggles and skin protection to prevent burns. UV lights also require frequent, routine maintenance to monitor the intensity of the light and can be costly to install or replace.

Microorganisms are constantly being shed from exposed skin and mucous membranes, so masks, drapes, hoods, and gowns are used as barriers to decrease shedding into the air and prevent wound contamination. These barriers, even when wet, are most effective when their pore size prevents passage of bacteria. Several woven fabrics and nonwoven materials are virtually impermeable to bacteria (32). When drapes and gowns made from such nonwoven disposable material were used in a recent study, a reduction in wound infections occurred (33). Reusable gowns made of tightly woven cotton treated with a water repellent prevent passage of bacteria, provided they have not been laundered and sterilized more than 75 times (34). Some gowns are made entirely of impermeable materials, and others have these materials in critical areas, such as in the front and on the sleeves. Surgical team members may get uncomfortably hot in gowns made only of impermeable materials unless the room temperature is lowered or ventilation is increased.

Wearing shoe covers or regularly cleaned shoes has been recommended as a means of preventing transmission of bacteria from shoes (9). However, in one study, no significant differences in floor contamination were seen when ordinary shoes, clean shoes, or shoe covers were worn (35). There have been no controlled clinical studies to evaluate the role of shoe covers in preventing or reducing surgical wound infections. Furthermore, there is no strong theoretical rationale for their use or indication that the benefits expected from them are cost effective.

In the modern, well-managed OR, the risk of infection related to the inanimate environment appears low. This is due, in great part, to adequate sterilization of surgical devices, ventilation systems that provide clean air, and adequate cleaning of the OR. Environmental culturing and special cleaning after "dirty" cases are not recommended. There is no evidence that special cleaning procedures, e.g., "dirty case routines," are necessary. Some architectural designs incorporated into ORs may be useful in maintaining a clean environment (36). Others, however, such as floor plans including a central clean area and a peripheral traffic corridor, have not been proven to be especially useful. In addition, tacky or antiseptic mats placed at the entrance to OR suites to reduce carriage of microorganisms on shoes or stretcher wheels have not been shown to reduce the risk of infection.

The most important measure to prevent wound infections is operative technique. Poor technique can result in inadvertent contamination of the wound (for example, an accidental perforation of the bowel during an abdominal operation), may prolong the operation, and may result in a wound that cannot adequately resist infection because it contains devitalized tissues or foreign bodies. Since the risk of wound infection increases with the length of the operation, an expeditious operation is important (2,5,7,12). However, the surgeon must balance the need to operate quickly with the need to handle tissues gently, reduce bleeding and hematoma formation, eradicate dead space, and minimize devitalized tissue and foreign materials in the wound. Other prevention techniques are not as well established as those just mentioned but appear prudent to use when possible. These are use of fine and monofilament rather than thick or braided suture and minimal use of suture and cautery. Technique applies not only to a surgeon's skill in handling the wound, but also to skill in supervising the surgical team and maintaining professional decorum that facilitates expeditious and successful operations. Poor discipline in the OR can result in mistakes and sloppy aseptic technique.

Once a surgeon has finished training, surgical habits might not be easy to change, but improvement may be stimulated by calculating and informing surgeons of their rates of wound infections. Traditionally, such efforts have been primarily focused on measuring the surgical wound infection rates following clean operations and reporting these rates to practicing surgeons (2,10). Two recent reports, however, demonstrate the effectiveness of not limiting surgical wound surveillance and reporting programs exclusively to clean operations (3,11). The first report, from the CDC SENIC Project, showed that establishing an infection surveillance and control program which included reporting surgeon-specific rates led to a reduction in hospitals' overall surgical wound infection rates of approximately 35% (11). Moreover, the report indicated that programs reporting such surgical wound infection rates were just as effective in reducing infection rates in contaminated or dirty cases as in clean or clean-contaminated cases. The other report, a 5-year prospective study in a large Veterans Administration Medical Center that involved surveillance and reporting of clean, clean-contaminated, and contaminated surgical wound infection rates, demonstrated a 55% reduction in the incidence of surgical wound infections and a savings of nearly $750,000 in hospital costs over the study period (3). Overall wound infection rates and clean-contaminated wound infection rates were significantly lower than baseline rates in each year of the study.

The postoperative period usually does not contribute greatly to the risk of surgical wound infections. Nevertheless, wounds can become contaminated and later become infected if they are touched by contaminated hands or objects after the operation, especially if the wound is left open or if a drain is used. Until wound edges are sealed and the wound is healing (about 24 hours after the operation for most wounds), wounds are covered with sterile dressings to reduce the risk of such contamination. A transparent, semipermeable membrane dressing has been developed for use on wounds because the dressing does not need to be removed for the wound to be observed; the effect of use of this dressing on wound infection rates is unknown. Most dressings are occasionally removed to observe the wound; the frequency of removal depends on such factors as the type of wound and the presence of infection, drainage, moisture, pain, or fever. Personnel taking care of wounds can reduce the risk of contamination by washing their hands and using instruments to handle dressings and tissues (the no-touch technique) or, if touching the wound is necessary, wearing sterile gloves.

In the postoperative period, the risk of wound infection can be reduced by adequate wound drainage. If not allowed to drain freely, blood, body fluids, pus, and necrotic material collect in a wound and provide a growth medium for microorganisms. However, if a wound is drained, the skin cannot be completely closed, and microorganisms can enter the wound or deeper structures and cause infection. Thus, surgeons routinely drain only wounds expected to produce significant amounts of blood or other drainage and use closed drainage in preference to open drainage (37,38). If a drain is used, having it enter through an adjacent, separate stab wound rather than the primary surgical wound will reduce the risk of infection. For dirty wounds, delaying wound closure is preferable to inserting a drain which increases the risk of infection (39); delayed wound closure is also useful for many contaminated wounds.

A patient's intrinsic susceptibility to infection is also important in determining the risk of infection. Unlike many other risk factors, host susceptibility is often not easily altered. If the operation can be delayed, some host factors can be altered: 1) Some diabetics can have their blood glucose better controlled, 2) some patients on adrenal glucocorticoids may be able to discontinue them or have the dosage reduced, and 3) severely malnourished patients can receive oral or parenteral hyperalimentation. However, there is no definitive evidence that these interventions will reduce the risk of infection. In each example and in others in which host susceptibility can be altered, the physician must weigh the potential benefits of the alteration against the risks of a delayed operation and potential complications of the intervention.

For some operations, prophylactic antimicrobials are a means of reducing the risk of wound infections. Reviews of antimicrobial prophylaxis for surgery that deal with selection of agents and duration of therapy are available (9,40-42). Prophylaxis is most useful for operations associated with a moderate level of contamination (clean-contaminated operations). Prophylaxis is not generally indicated for clean operations unless the consequences of infection are severe or life-threatening, for example, prosthetic (implant) orthopedic and cardiovascular surgery.


RECOMMENDATIONS

  1. Preparation of the Patient Before Operation
    1. If the operation is elective, all bacterial infections that are identified, excluding ones for which the operation is performed, should be treated and controlled before the operation. Category I
    2. If the operation is elective, the hospital stay before the operation should be as short as possible. Category II
    3. If the operation is not urgent and the patient is malnourished, the patient should receive enteral or parenteral nutrition before the operation. Category II
    4. If the operation is elective, the patient should bathe (or be bathed) the night before with an antimicrobial soap. Category III
      1. Unless hair near the operative site is so thick that it will interfere with the surgical procedure, it should not be removed. Category II
      2. If hair removal is necessary, it should be done either by clipping or using a depilatory rather than shaving. Category II
    5. The area around and including the operative site should be washed and an antimicrobial preoperative skin preparation applied from the center to the periphery. This area should be large enough to include the entire incision and an adjacent area large enough for the surgeon to work during the operation without contacting unprepared skin. Category II (Persons responsible for selecting commercially marketed antimicrobial preoperative skin preparations can obtain information about categorization of products from the Center for Drugs and Biologics, Division of OTC Drug Evaluation, FDA. In addition, information published in the scientific literature, presented at scientific meetings, documented by manufacturers and obtained from other sources deemed important may be considered.)
    6. For major operations involving an incision and requiring use of the operating room (OR), the patient should be covered with sterile drapes in such a manner that no part of the patient is uncovered except the operative field and those parts necessary for anesthesia to be administered and maintained. Category II
  2. Preparation of the Surgical Team
    1. Everyone who enters the OR during an operation should at all times wear a high-efficiency mask to fully cover the mouth and nose and a cap or hood to fully cover hair on the head and face. Category I
    2. Everyone who enters the OR should wear shoe covers. Category III
      1. The surgical team, that is, those who will touch the sterile surgical field, sterile instruments, or an incisional wound, should scrub their hands and arms to the elbows with an antimicrobial surgical hand scrub preparation before each operation. Scrubbing should be done before every procedure and take at least 5 minutes before the first procedure of the day. Category I (Persons responsible for selecting commercially marketed surgical hand scrubs can obtain information about categorization of products from the Center for Drugs and Biologics, Division of OTC Drug Evaluation, FDA. In addition, information published in the scientific literature, presented at scientific meetings, documented by manufacturers, and obtained from other sources deemed important may be considered.)
      2. Between consecutive operations, scrubbing times of 2 to 5 minutes may be acceptable. Category II
      1. After the hands are scrubbed and dried with sterile towels, the surgical team should don sterile gowns. Category I
      2. Gowns used in the OR should be made of reusable or disposable fabrics that have been shown to be effective barriers to bacteria, even when wet. Category II
      1. The surgical team should wear sterile gloves. If a glove is punctured during the operation, it should be changed as promptly as safety permits. Category I
      2. For open bone operations and orthopedic implant operations, 2 pairs of sterile gloves should be worn. Category II
  3. Preparation and Maintenance of Operating Room Environment
    1. OR ventilation should include a minimum of 20 air changes per hour, of which at least 4 should be fresh air. All inlets should be located as high above the floor as possible and remote from exhaust outlets of all types. All air, recirculated or fresh, should be filtered (at least 90% efficiency) before it enters the OR. The surgical suite should be under positive pressure relative to the surrounding area. Category II
    2. All OR doors should be kept closed except as needed for passage of equipment, personnel, and the patient -- the number of personnel allowed to enter the OR, especially after an operation has started, should be kept to a minimum. Category II
    3. The OR should be cleaned between surgical operations. Category II
    4. Routine microbiologic sampling of the air or environmental surfaces should not be done. Category I
    5. Use of tacky or antiseptic mats at the entrance to the OR is not recommended for purposes of infection control. Category I
    6. Surgical instruments and supplies should be sterilized as outlined in the current edition of the CDC Guideline for Handwashing and Hospital Environmental Control (This recommendation is not categorized since it refers to multiple recommendations that have been categorized elsewhere.)
  4. Operative Technique
    1. The surgical team should work as efficiently as possible in order to handle tissues gently, prevent bleeding, eradicate dead space, minimize devitalized tissue and foreign material in the wound, and reduce the length of the operation. Category I
    2. Incisional wounds that are classified as "dirty and infected" should not ordinarily have skin closed over them at the end of an operation, that is, they should not ordinarily be closed primarily. Category II
    3. If drainage is necessary for an uninfected wound, a closed suction drainage system should be used and placed in an adjacent stab wound rather than the main incisional wound. Category II
  5. Wound Care
    1. Personnel should wash their hands before and after taking care of a surgical wound. Category I
    2. Personnel should not touch an open or fresh wound directly unless they are wearing sterile gloves or use no-touch technique. When the wound has sealed dressings may be changed without gloves. Category I
    3. Dressings over closed wounds should be removed or changed if they are wet or if the patient has signs or symptoms suggestive of infection, for example, fever or unusual wound pain. When the dressing is removed, the wound should be evaluated for signs of infection. Any drainage from a wound that is suspected of being infected should be cultured and smeared for Gram stain. Category I
  6. Prophylactic Antimicrobials
    1. Parenteral antimicrobial prophylaxis is recommended for operations that 1) are associated with a high risk of infection or 2) are not frequently associated with infection but, if infection occurs, are associated with severe or life-threatening consequences, for example, cardiovascular and orthopedic operations involving implantable devices. Category I
    2. Antimicrobials selected for use for prophylaxis should have been shown to be safe and effective for prophylaxis of operative wound infections in well-designed, controlled trials whose results have, been published. Category I
    3. Parenteral antimicrobial prophylaxis should be started shortly before the operation and should be promptly discontinued after the operation. Category I (For cesarean sections, prophylaxis is usually given intraoperatively after the umbilical cord is clamped.)
  7. Protection of Patients from Other Infected Patients or Personnel
    1. Patients with potentially transmissible wound or skin infections should be placed on isolation precautions according to the current edition of the CDC Guideline for Isolation Precautions in Hospitals. (This recommendation is not categorized, since the recommendations for isolation precautions are not categorized.)
    2. Personnel with potentially transmissible conditions, for example, Herpes simplex infections of fingers and hands, group A streptococcal disease, or S. aureus skin lesions, should be managed according to the current edition of the CDC Guideline for Infection Control in Hospital Personnel. (This recommendation is not categorized since it refers to several recommendations that have been categorized elsewhere.)
    3. Routine culturing of personnel should not be done. Category I
  8. Surveillance and Classification
    1. At the time of operation or shortly after, all operations should be classified and recorded as clean, clean-contaminated, contaminated, or dirty and infected (see text for definitions). Category II
    2. The person in charge of surveillance of surgical patients should gather the information necessary to compute the classification- specific wound infection for all operations in the hospital. These rates should be computed periodically and made available to the infection control committee and the department of surgery. Category II
    3. Procedure-specific wound infection rates should be computed periodically for the hospital and all active surgeons so that they can compare their own rates with those of others; the rates can be coded so that names do not appear. Category II
    4. Increases in wound infection rates should be evaluated. If an outbreak is confirmed, appropriate epidemiologic studies should be initiated. Category I
    5. An effort should be made to contact discharged patients to determine the infection rate for the 30 days after operation. Category III

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