Surgical Site Infection Prevention

1. Antibiotic use
  1. Antibiotic use
    1. All patients having surgery should receive appropriate prophylactic antibiotics except for some clean surgical procedures (See Table 1) (Level of evidence: High)
    2. Patients, who are said to have an antibiotic allergy, should have an allergy history taken to learn what antibiotic caused the reaction and clarify the type of reaction. For penicillin cross-reactions, only a history of severe/anaphylactic reactions (for example hives, hypotension, respiratory difficulties) necessitates an alternative to beta-lactams (Level of evidence: Moderate)
    3. Antibiotics should be dosed to optimize tissue concentrations (See Table 2) (Level of evidence: Moderate)
    4. Antibiotics should be administered within 60 minutes before surgical incision/tourniquet inflation. Vancomycin and fluoroquinolones require a longer infusion time and should be initiated to ensure completion within 60 minutes of incision (See Table 2) (Level of evidence: Low-Moderate)
    5. Antibiotics should be re-dosed if the duration of the procedure exceeds two half-lives of the antibiotic (Table 1) or there is excessive blood loss (>1.5L in adults) for all antibiotics except vancomycin (Level of evidence: Very low)
    6. Antibiotics should not be given postoperatively unless there is an indication other than for prophylaxis (Level of evidence: High)
    7. Patients who have indwelling drains or intravascular catheters do not require additional prophylaxis (Level of evidence: Moderate)
    8. In MRSA colonized patients, vancomycin should be added to the regimen (See Section 6) (Level of evidence: Moderate)
    9. Patients receiving therapeutic antibiotics preoperatively are at increased risk for surgical site infections. The optimal method of prophylaxis is unknown, but unless the therapeutic antibiotic provides coverage for SSI prophylaxis, prophylactic antibiotics should be administered. As well, these antibiotics should be timed to ensure maximal tissue concentration at incision (Level of evidence: Very low)
2. Perioperative normothermia
  1. Perioperative normothermia
    1. Active measures should be taken to ensure that the patient’s body temperature is greater than 36°C perioperatively
      1. If the patient is at high risk of hypothermia or if his/her temperature is less than 36°C preoperatively, forced-air warmers should be started prior to induction to ensure a body temperature greater than 36°C prior to surgery (Level of evidence: Moderate)
    2. The use of forced-air warming systems (Level of evidence: Moderate) and warmed IV and irrigation fluids (Level of evidence: Very low) should be used intraoperatively to maintain body temperature greater than 36°C for patients during the surgical procedure
      1. Warming systems should not be used in patients undergoing surgery where intraoperative hypothermia is intended (i.e. off-pump surgery)
3. Preoperative skin preparation
  1. Preoperative skin preparation
    1. Patients should be prepped with alcohol-based chlorhexidine gluconate (2% chlorhexidine gluconate and 70% isopropyl alcohol) with the following exceptions: (Level of evidence: Moderate)
      1. Povidone iodine should continue to be used for ophthalmic procedures and those involving the inner ear or mucous membranes
      2. Procedures where there is no time for alcohol solutions to dry (eg: in trauma), an aqueous-based antiseptic solution should be used and allowed to dry
      3. Infants less than 2 months old
    2. Alcohol-based antiseptics are flammable in operative procedures involving electrosurgery (i.e. electrocautery) so pooling on drapes and the patient should be avoided. The antiseptic solution should also be allowed time to dry completely (~ 3 minutes, longer in areas with excess hair) to limit fire hazard (Level of evidence: Low)
    3. Patients should bathe or shower the entire body and head prior to surgery using plain or antimicrobial soap
4. Preoperative hair removal
  1. Preoperative hair removal
    1. Hair removal should not be performed for the purposes of SSI prevention. If hair removal is necessary, clippers should be used (Level of evidence: Moderate)
5. Staphylococcus aureus decolonization
  1. Staphylococcus aureus decolonization
    1. In cardiac surgery and orthopedic/spinal surgery with hardware insertion, Staphylococcus aureus screening with nasal swab and decolonization of carriers with intranasal mupirocin 2% ointment BID and chlorhexidine-gluconate body wash for 5 days before surgery should be considered (Level of evidence: Low)
    2. For MRSA carriers, decolonization in conjunction with hospital infection control practitioners or infectious disease consultants should be considered (Level of evidence: Very low)
6. Special considerations
  1. Special considerations
    1. Antimicrobial-coated sutures may be used to reduce SSIs (Level of evidence: Moderate)
    2. Local application of vancomycin powder in spine surgery is controversial and no strong recommendation can be made with the current evidence (Level of evidence: Very low)
    3. Antibiotic impregnated shunts may be beneficial in reducing central nervous system shunt infections but no strong recommendation can be made with the current evidence (Level of evidence: Very low)
    4. Endocarditis prophylaxis is only required in patients with a few predisposing cardiac conditions prior to specific dental procedures (Level of evidence: Low) and manipulation of the respiratory mucosa (Level of evidence: Very low)

Table 1. Procedure Specific Recommended Agents and Duration

1. Cardiac
Division Recommended Agents B-lactam allergy Recommended agents
Cardiac
Coronary artery bypass (CABG), valve replacement (+/- CABG), other cardiac procedures cefazolin vancomycin
Ventricular assist devices, Device insertion (e.g. pacemaker) cefazolin vancomycin
Cardiac catheterization, Transesophageal echocardiogram None None
2. General
Division Recommended Agents B-lactam allergy Recommended agents
General
Gastroduodenal/esophageal/ distal pancreatic resection cefazolin vancomycin + aminoglycoside
Percutaneous endoscopic gastrostomy (PEG) cefazolin vancomycin + aminoglycoside
Biliary tract- laparoscopic procedure- Elective low risk None None
Biliary tract- laparoscopic procedure - High risk emergency, inserting prosthetic device, diabetes, risk of intraoperative gallbladder rupture/conversion to open, age >70 years, ASA ≥3, reintervention within 1 month, acute cholecystitis, obstructive jaundice, CBD stones, nonfunctional GB, pregnancy, immunosuppression
Biliary tract- open procedure
Liver resection
cefazolin vancomycin + aminoglycoside
Colorectal, small bowel, appendectomy
Pancreaticoduodenectomy (b) , + aminoglycoside + metronidazole
Hernia repair- Hernioplasty, herniorrhaphy cefazolin vancomycin
Low risk anorectal procedures: hemorrhoidectomy, fistulotomy, sphincterotomy None None
3. Thoracic
Division Recommended Agents B-lactam allergy Recommended agents
Thoracic
Non-cardiac procedures (e.g. lobectomy, pneumonectomy, lung resection, and thoracotomy) cefazolin vancomycin
Thoracentesis or chest tube insertion for non-traumatic indications (e.g. spontaneous pneumothorax) Mediastinoscopy None None
4. Head and neck
Division Recommended Agents B-lactam allergy Recommended agents
Head and neck
Clean: no incision through oral/nasal/pharyngeal mucosa (e.g. parotidectomy, thyroidectomy, and submandibular gland excision) None None
Clean with placement of prosthetic material (excludes tympanostomy tubes) cefazolin vancomycin + metronidazole(d)
Clean-contaminated (incision through oral/pharyngeal mucosa): cancer surgery and other clean-contaminated procedures with the exception of tonsillectomy and functional endoscopic sinus procedures cefazolin + metronidazole vancomycin + aminoglycoside + metronidazole(e)
5. Neurosurgery
Division Recommended Agents B-lactam allergy Recommended agents
Neurosurgery
Elective craniotomy, stereotactic brain biopsy, cerebrospinal fluid-shunting procedures, ICP monitor, external ventricular drain, and implantation of intrathecal pumps cefazolin vancomycin
Endoscopic transsphenoidal neurosurgery Cefazolin Vancomycin + aminoglycoside
(There is a minimal data for the best regimen in such patients)
6. Orthopedic
Division Recommended Agents B-lactam allergy Recommended agents
Orthopedic
Arthroscopy without graft implantation None None
Spinal procedures with and without instrumentation, hip fracture repair, Implantation of internal fixation devices (e.g., nails, screws, plates, wires) and total joint replacement cefazolin Vancomycin
If emergent surgery precludes the infusion time for vancomycin, clindamycin may be used instead
7. Urologic
Division Recommended Agents B-lactam allergy Recommended agents
Urologic
Prior to stone removal or invasive procedures involving mucosal bleeding/trauma, obtain urine sample and treat based on culture and sensitivity result
Cystoscopy/Shock wave lithotripsy
• no risk factors
None
Cystoscopy/Shock wave lithotripsy:
  • Risk factors: advanced age, immunocompromised, large stone burden, history of pyelonephritis/infected stone, prolonged catheterization, nephrostomy tubes
  • Manipulation: Prostatectomy, biopsy, foreign body removal, urethral dilation, stent placement/removal
Ureteroscopy
Percutaneous nephrolithotomy
Transrectal prostate biopsy(f)
If no hospitalization in last year, recent antibiotic use from the class, or other risks for resistance:
ciprofloxacin 500mg PO or cefazolin (if no beta-lactam allergy)
If risk of Gram-negative resistance:
aminoglycoside or ceftriaxone 1g (if no beta-lactam allergy)
Percutaneous renal surgery cefazolin vancomycin
Open or Laparoscopic:
without entry into bowel/vagina
cefazolin vancomycin + aminoglycoside(g)
Open or Laparoscopic:
involving manipulation of bowel/vagina
cefazolin + metronidazole vancomycin + aminoglycoside + metronidazole(a)
8. Vascular
Division
Brachiocephalic procedures and carotid endarterectomy without prosthetic material
Angiography, angioplasty, thrombolysis, vascular stenting
None None
Arterial surgery
Graft placement or repair
cefazolin vancomycin
9. Plastics
Division Recommended Agents B-lactam allergy Recommended agents
Plastics
Clean without risk factors (not breast surgery) None None
Clean - high risk
  • prosthetic material, skin irradiation, traumatic/crush hand injuries, flap reconstruction, panniculectomy, injuries requiring amputation/reconstructive limb surgery, injuries involving bone, joint, tendon (except open flexor tendon injuries) or nerve
Clean-contaminated
cefazolin vancomycin
Breast surgery cefazolin vancomycin
10. Ophthalmic
Division Recommended Agents B-lactam allergy Recommended agents
Ophthalmic
1 drop every 5-15 min for 5 doses:
Topical neomycin-polymyxin B-gramicidin
or
gatifloxacin or moxifloxacin
Optional to add at the end of the procedure:
subconjunctival injection cefazolin 100mg or intracameral cefazolin 1-2.5mg or cefuroxime 1 mg
11. Obstetrical/Gynecological
Division Recommended Agents B-lactam allergy Recommended agents
Obstetrical/Gynecological
Caesarean section(i)
Therapeutic termination of pregnancy Doxycycline 100 mg PO 1 hour before procedure, then 200 mg PO post-procedure

Notes

1. ASHP recommends numerous regimens in Beta-lactam allergic patients.
ASHP recommends numerous regimens in Beta-lactam allergic patients. We have avoided using clindamycin and added vancomycin to the recommended aminoglycoside and metronidazole regimen because Gram-positive organisms including S. aureus are common causes of SSIs (Blumetti Surgery 2007 142:704-711; Hidron Infection Control and Hospital Epidemiology, Vol. 29, No. 11 (November 2008), pp.996-1011)
2. The addition of metronidazole for pancreaticoduodenectomy is controversial and not in the ASHP guidelines.
The addition of metronidazole for pancreaticoduodenectomy is controversial and not in the ASHP guidelines. However, these surgeries are high risk for infection, involve bowel manipulation, anaerobic coverage is used in other centers (Fong JAMA Surg. 2016;151(5):432-439), and Bacteroides spp. are isolated in SSIs (Sugiura World J Surg (2012) 36:2888-2894; Sudo World J Surg (2014) 38:2952-2959).
3. There is a strong association of preoperative biliary stenting with bacteriobilia
There is a strong association of preoperative biliary stenting with bacteriobilia (OR 725.3 [95% CI 155.6-3380.5]; P < .001), which in turn is strongly associated with postoperative wound infection (OR 2.5 [95% CI 0.583-11.05]; P = .05) (Fong JAMA Surg. 2016;151(5):432-439).
4. The ASHP guidelines recommend clindamycin for Beta-lactam allergic patients in head and neck surgery
The ASHP guidelines recommend clindamycin for Beta-lactam allergic patients in head and neck surgery. Clindamycin prophylaxis is associated with higher SSIs in head and neck free flap surgeries (Durand Laryngoscope, 125:1084–1089, 2015, Mitchell JAMA Otolaryngol Head Neck Surg. 2015;141(12):1096-1103), major ablative head and neck resection with free tissue transfer (Pool et al Otolaryngology–Head and Neck Surgery 2016, Vol. 154(2) 272–278), laryngectomy for larynx cancer (Langerman Otolaryngology–Head and Neck Surgery 2015, Vol. 153(1) 60–68), and other head and neck oncologic surgery (Weber Arch Otolaryngol Head Neck Surg. 1992;118:1159-1163; Langerman Otolaryngology–Head and Neck Surgery 2016, Vol. 154(6) 1054–1063). There is also a higher risk for C. difficile infections with clindamycin (Langerman Otolaryngology–Head and Neck Surgery 2015, Vol. 153(1) 60–68).
5. The risk of infection after transrectal prostate biopsy is high because of the nature of the procedure and increasing resistance patterns of E. coli, particularly for fluoroquinolones and 1st generation cephalosporins.
The risk of infection after transrectal prostate biopsy is high because of the nature of the procedure and increasing resistance patterns of E. coli, particularly for fluoroquinolones and 1st generation cephalosporins. Patients with increased risk of harboring resistant organisms (recent antimicrobials, infections, travel), should have perirectal culture swab performed prior to biopsy according to the Canadian Urological Association to guide prophylaxis choice. However, this is not routinely done and would change workflow and significantly impact laboratory resources. The use of ciprofloxacin in combination with trimethoprim/sulfamethoxazole is not usually effective since fluoroquinolone resistant E.coli are often resistant to TMP-SMX (Al-Busaidi I. Infect Control Hosp Epidemiol. 2015 May;36(5):614-6).
6. We have recommended vancomycin instead of clindamycin to improve Gram-positive coverage and minimize the adverse effects from clindamycin.
We have recommended vancomycin instead of clindamycin to improve Gram-positive coverage and minimize the adverse effects from clindamycin. The ASHP recommends aminoglycoside alone with or without clindamycin. The American Urological Association recommends aminoglycoside and clindamycin in these patients but there is minimal evidence for such clindamycin use.
7. The role for azithromycin 500mg in addition to standard prophylaxis for nonelective caesarean section is supported by a recent multicenter RCT (Tita N Engl J Med 2016;375:1231-41).
The role for azithromycin 500mg in addition to standard prophylaxis for nonelective caesarean section is supported by a recent multicenter RCT (Tita N Engl J Med 2016;375:1231-41). There was reduction in endometritis and wound infections compared to standard prophylaxis (6% vs 12% placebo; OR 0.51; 95% CI 0.38-0.68; p < 0.001). Before widely adopting this practice, baseline assessment of postoperative endometritis and wound infection rates should be performed to assess the need for azithromycin and to compare to post-implementation rates.
8. The ASHP recommends aminoglycoside and clindamycin
The ASHP recommends aminoglycoside and clindamycin. There is minimal evidence for this regimen, and we recommend vancomycin instead of clindamycin to improve Gram-positive coverage and minimize the adverse effects of clindamycin.

Table 2.

Recommended dosing and re-dosing of antimicrobial prophylaxis
Agent Adult dose Pediatric dose(max dose should not exceed the recommended adult dose) Intra-operative re-dosing (from initiation of pre-op dose)
Cefazolin 2 g
3 g if weight > 120kg
30mg/kg IV
(max dose: 2g)
q4hrs if
CrCl > 30mL/min
(Max 6g / 24hrs)
Aminoglycoside:a
Gentamicin or Tobramycin
3 mg/kga
(round to nearest 20 mg)
2.5 mg/kg If CrCl ≥ 60 ml/min: q8h
If CrCl < 40-60 ml/min: q12h
If CrCl < 40: no re-dose
Neonates: 6 hours
Metronidazole 500 mg 15 mg/kg Neonates < 1200g: 7.5mg/kg q12h
Neonates: No repeat doses
Vancomycinc 15 mg/kg round nearest 250mg
(max 2g/dose)
Administer < 1g over 60 min,
> 1g-1.5g over 90min
> 1.5g over 120min
15 mg/kg
(max dose: 1g)
q12 hrs No re-dose if CrCl < 30 ml/min Pediatrics: 6 hours Neonates: 10 hours Do not redose with intra-op blood loss
  1. adose based on actual body weight (ABW) unless obese. If ABW >20% above ideal body weight (IBW), use Dosing Weight= IBW + 0.4*(ABW – IBW)
  2. IBW Men: 50kg + 2.3kg(x inches above 60in); IBW Women: 45.5kg + 2.3kg(x inches above 60in)
  3. bdose should be based on total body weight
  4. c if tourniquet is used, entire dose should be infused prior to inflation