Updated October 2025
SSI Prevention and Management
Surgical Site Infections: Prevention and Management
Surgical site infections (SSIs) remain among the most common healthcare-associated infections in surgical patients. Evidence-based bundles that combine timely antibiotic prophylaxis, skin and nasal decolonization, glycemic and temperature control, appropriate hair removal, antiseptic preparation, and perioperative workflow discipline reduce SSI risk. Early recognition and stratified management—ranging from wound care and culture-directed antibiotics to source control—optimize outcomes.
Clinical question
What are the most effective, evidence-based strategies to prevent and manage surgical site infections across the perioperative continuum?
SurgeryInfection PreventionAntimicrobial StewardshipQuality ImprovementPerioperative Care
Key points
Bundle the basics
Combine timely systemic prophylaxis, chlorhexidine-alcohol prep, glycemic control, normothermia, and proper hair removal to achieve additive risk reduction [2], [3], [4], [6], [1].
Hit the prophylaxis window
Administer antibiotics within 60 minutes (120 minutes for vancomycin/fluoroquinolones), redose intraoperatively per drug half-life and blood loss [2], [3], [4], [1].
Risk-stratify and optimize
Address modifiable risks preop: glucose, smoking, MRSA colonization, obesity, and preop bathing; tailor strategies to procedure risk profile [2], [3], [4].
Recognize and intervene early
Fever, erythema, pain, drainage: obtain cultures and pursue timely source control; avoid unnecessary antibiotics for superficial inflammation without infection [3], [7], [4].
Standardize with checklists
Use operating room checklists and maintenance protocols (air handling, cleaning, traffic control) to sustain performance and reduce variation [4], [6].
Evidence highlights
Antibiotics within 60 min pre-incision linked to lower SSI rates [1]
Timing of prophylaxis
Antibiotic prophylaxis recommended across major guidelines despite limited RCTs [2], [3], [4]
Guideline consensus
SSIs are the most common HAIs in surgical departments [5]
Burden
Evidence-Based SSI Prevention Across the Surgical Timeline
Integrate patient optimization, aseptic technique, and antimicrobial stewardship into a coherent bundle. Evidence is strongest for antibiotic timing, skin antisepsis, and glycemic/temperature control; benefit is additive when bundled.
1
Preoperative optimization
• Encourage preoperative bathing with chlorhexidine where feasible; ensure thorough patient education [3], [4]. • Screen and decolonize MRSA carriers in high-risk procedures (e.g., cardiac, orthopedic) with intranasal mupirocin and chlorhexidine bathing when adopted locally [2], [4]. • Optimize glucose (target perioperative glucose generally <180 mg/dL) and smoking cessation, treat remote infections, and manage obesity when possible [2], [3], [4].
2
Hair removal and skin preparation
• If hair removal is required, use clippers immediately before surgery—avoid razors to reduce microabrasions [3], [4]. • Prepare skin with an alcohol-based chlorhexidine solution unless contraindicated; allow adequate drying time to maximize antimicrobial effect and fire safety [2], [3], [4].
3
Antimicrobial prophylaxis
• Administer appropriate-spectrum antibiotics within 60 minutes prior to incision (120 minutes for vancomycin/fluoroquinolones); redose per half-life, prolonged cases, or major blood loss; discontinue within 24 hours for most procedures to support stewardship [2], [3], [4], [1]. • Despite limited RCTs, guidelines consistently recommend prophylaxis due to strong observational and pathophysiologic rationale [2].
4
Intraoperative practices
• Maintain normothermia with active warming; hypothermia increases SSI risk [2], [4]. • Control glucose intraoperatively and postoperatively (e.g., insulin protocols for diabetics and select nondiabetics) [2], [4]. • Limit OR traffic, ensure proper air handling, instrument sterilization, and environmental cleaning; adhere to sterile technique discipline [4], [6].
5
Postoperative wound care and stewardship
• Use sterile dressings for at least 24–48 hours and educate patients on signs of infection [3], [7]. • Avoid routine postoperative systemic antibiotics in clean procedures; use only for diagnosed infections or specific indications [2], [3], [4]. • Consider negative-pressure wound therapy for high-risk incisions per institutional protocol and evidence base [2], [4].
Diagnosis and Management of SSIs
Differentiate superficial, deep incisional, and organ/space SSIs; prioritize source control, culture-guided therapy, and hemodynamic stabilization.
Diagnose and classify
Confirm timing (within 30 days of surgery or 90 days for implants) and depth: superficial, deep incisional, organ/space [3], [4].
Look for erythema, purulent drainage, pain, fever; use ultrasound/CT when deep or organ/space infection suspected [3], [7].
Obtain wound cultures after debridement or aspiration; avoid swab of intact surface when possible [3], [4].
Immediate actions
Assess severity and sepsis; initiate resuscitation if unstable [3], [4].
Source control: open incision for drainage, remove necrotic tissue, and consider reoperation for deep/organ-space infections [3], [4].
Begin empiric antibiotics when systemic signs, deep/organ-space infection, prosthetic involvement, or high-risk hosts are present—then de-escalate to culture results [3], [4].
Empiric therapy principles
Cover likely flora by procedure: gram-positives (including MRSA risk) for clean procedures; add gram-negatives/anaerobes for GI or contaminated fields [2], [3], [4].
Adjust for local antibiogram and patient risks (MRSA colonization, prior antibiotics) [2], [4].
Typical durations: superficial incisional often no systemic antibiotics after drainage; deep incisional 7–14 days; organ/space 2–4 weeks with adequate source control—tailor to response and source [3], [4].
Wound care and follow-up
Perform regular wound assessment; consider negative-pressure therapy in high-risk wounds [2], [4].
Educate patients on signs of infection and when to seek care [3], [7].
Reassess at 48–72 hours; narrow antibiotics and plan definitive closure when infection controlled [3], [4].
When to escalate
Hemodynamic instability, necrotizing infection concerns, or failure to improve within 48–72 hours despite appropriate therapy [3], [4].
Implant or prosthesis involvement—coordinate with surgical team for debridement and hardware management [3], [4].
Recurrent infections or unusual organisms—consult infectious diseases and consider imaging for retained collections [3], [4].
Programmatic Elements and Quality Metrics
Structured programs with surveillance, feedback, and multidisciplinary ownership sustain SSI reductions.
Core program components
Adopt a procedure-specific SSI bundle with explicit compliance metrics (antibiotic timing, skin prep, temperature, glucose) [2], [4].
Run perioperative safety checklists and briefings; empower teams to halt for noncompliance [4], [6].
Provide regular feedback on process adherence and SSI rates to surgical teams and leadership [4].
Operating room environment
Maintain proper air exchanges and pressure gradients; minimize door openings and traffic [6].
Standardize instrument sterilization, terminal cleaning, and turnover disinfection protocols [4], [6].
Audit and coach on sterile technique and skin prep application fidelity [4].
Antimicrobial stewardship
Restrict prolonged postoperative prophylaxis; stop within 24 hours for most procedures [2], [3], [4].
Standardize redosing rules and weight-based dosing; monitor adherence in real time [2], [4].
Integrate SSI bundle with stewardship review to curb resistance and C. difficile risk [2], [4].
References
Source material
Primary literature that informs this article.
Surgical Site Infection Prevention: How We Do It - PMC
pmc.ncbi.nlm.nih.gov
Surgical Site Infection Prevention: A Review | Surgery
jamanetwork.com
Surgical site infections: prevention and treatment | Guidance
www.nice.org.uk
Strategies to prevent surgical site infections in acute-care ...
pmc.ncbi.nlm.nih.gov
ACOI Surgical Site Infections Management Academy...
journals.lww.com
Strategies to Prevent Surgical Site Infections in Acute Care ...
pmc.ncbi.nlm.nih.gov
Surgical Site Infection Basics | SSIs
www.cdc.gov
Perioperative Strategies for Surgical Site Infection Prevention
pubmed.ncbi.nlm.nih.gov