DRAFT FOR CONSULTATION Surgical site infection National Collaborating Centre for Women’s and Children’s Health Commissioned by the National Institute for Health and Clinical Excellence DRAFT FOR CONSULTATION April 2008 RCOG Press Surgical site infection: full guideline DRAFT (April 2008) page i of 165 DRAFT FOR CONSULTATION Contents Guideline Development Group membership and acknowledgements iv Guideline Development Group iv Acknowledgements iv Stakeholder organisations v Abbreviations ix Glossary of terms xi 1 Introduction 1 1.1 Surgical site infection 1 1.2 Aim of the guideline 4 1.3 Areas outside of the remit of the guideline 4 1.4 For whom is the guideline intended? 4 1.5 Who has developed the guideline? 5 1.6 Other relevant documents 5 1.7 Guideline methodology 5 1.8 Schedule for updating the guideline 9 2 Summary of recommendations and care pathway 10 2.1 Key priorities for implementation (key recommendations) 10 2.2 Summary of recommendations 11 2.3 Key priorities for research 14 2.4 Summary of research recommendations 15 2.5 Care pathway 16 3 Risk Factors 18 4 Information for patients 19 5 Preoperative phase 21 5.1 Preoperative showering 21 5.2 Hair removal 23 5.3 Patient theatre attire 26 5.4 Non-sterile theatre wear 26 5.5 Staff leaving the operating area in non-sterile theatre wear 27 5.6 Nasal decontamination 28 5.7 Mechanical bowel preparation 30 5.8 Hand decontamination (general) 32 5.9 Hand jewellery, artificial nails and nail polish 32 5.10 Antibiotic prophylaxis 33 6 Intraoperative phase 46 6.1 Hand decontamination (scrubbing) 46 6.2 Incise drapes 47 6.3 Use of gowns 50 6.4 Disposable drapes and gowns/ Reusable drapes and gowns 50 6.5 Gloves 51 6.6 Skin preparation with antiseptics prior to surgery 52 6.7 Diathermy 57 6.8 Maintaining patient homeostasis 58 6.9 Intracavity lavage and Wound Irrigation 65 6.10 Antiseptics and antimicrobials prior to wound closure 70 6.11 Closure methods 73 6.12 Wound dressings for SSI prevention 84 7 Postoperative phase 90 7.1 Clean technique compared with aseptic non-touch techniques for dressing changes 90 7.2 Postoperative cleansing of the wound 91 7.3 Postoperative topical antimicrobials for prevention of SSI in surgical wounds healing by primary intention 92 7.4 Dressing and antimicrobial impregnated dressings for the management of surgical wounds healing by secondary intention93 7.5 Debridement 95 Surgical site infection: full guideline DRAFT (April 2008) page ii of 165 Contents Appendix A Declarations of Interest 98 Appendix B Clinical questions 99 Appendix C Definitions of Surgical Site Infections 101 Appendix D Wound dressings for SSI prevention 107 Appendix E Cost-effectiveness of hair removal 108 Appendix F Cost effectiveness of mupirocin nasal ointment to prevent surgical site infection caused by S. aureus 110 Appendix G Cost-effectiveness of perioperative warming 117 Appendix H Cost effectiveness of closure methods 119 Appendix I Cost-analysis of wound dressings 121 Appendix J General principles for hand hygiene (EPIC) 123 Appendix K Postoperative cleansing of the wound 124 References 124 Index Search strategies CD-ROM Evidence tables CD-ROM Excluded studies CD-ROM Surgical site infection: full guideline DRAFT (April 2008) page iii of 165 DRAFT FOR CONSULTATION Guideline Development Group membership and acknowledgements Guideline Development Group GDG members Mark Collier Lead Nurse Consultant, Tissue Viability David Evans Patient/Consumer Representative Mark Farrington Consultant Medical Microbiologist Elizabeth Gibbs Patient/Consumer Representative Kate Gould Consultant Microbiologist (Clinical Advisor to the GDG) Helen Jenkinson Hygiene Code Implementation Manager Kathryn Kitson* Team Leader for Orthopaedic and Trauma Theatres David Leaper GDG Chair, Professor, Department of Wound Healing Matt Thompson Professor of Vascular Surgery Jennie Wilson Programme Leader, SSI Surveillance Service/ (*stood down December 2007 due to work commitments) National Collaborating Centre for Women’s and Children’s Health (NCC-WCH) staff Shona Burman-Roy Systematic Reviewer Katherine Cullen Health Economist Eva Gautam-Aitken Project Manager Paul Jacklin Senior Health Economist Ana Palanca Research Assistant Edmund Peston Document Supply Co-ordinator Roxana Rehman Work Programme Co-ordinator Andrew Welsh Editor Martin Whittle Clinical Co-Director Danielle Worster Information Scientist External Advisers John Black Consultant Surgeon Alice Jones Senior Sister in General and Emergency Surgery Grainne Nicholson Consultant Anaesthetist Acknowledgements Additional support was received from: • Anna Bancsi, Martin Dougherty, Debbie Pledge, Roz Ullman at the NCC-WCH • Caroline Keir at the National Institute for Health and Clinical Excellence (NICE) • The Patient and Public Involvement Programme (PPIP) for NICE • Judith Tanner, Nancy Dryburgh, Joan Webster and Sally Bell-Syers at the Cochrane Wounds group • Roberta Jenkins at the Scottish Intercollegiate Guidelines Network (SIGN) • National Collaborating Centre of Nursing and Supportive Care (NCC-NSC) and the members of the 2005 SSI Guideline Development Group Surgical site infection: full guideline DRAFT (April 2008) page iv of 165 DRAFT FOR CONSULTATION Stakeholder organisations 3M Health Care Limited Abbott Laboratories Limited Actamed Limited Activa Healthcare Ltd Acute Care Collaborating Centre Age Concern England Aguettant Limited Airedale General Hospital - Acute Trust All Wales Senior Nurses Advisory Group (Mental Health) Anglesey Local Health Board ARHAI Ashford and St Peters Hospitals NHS Trust Association for Perioperative Practice Association of British Health-Care Industries Association of Medical Microbiologists Association of NHS Occupational Physicians Association of Paediatric Emergency Medicine Association of Surgeons of Great Britain and Ireland Association of the British Pharmaceuticals Industry,(ABPI) AstraZeneca UK Ltd Barnet PCT Barnsley Hospital NHS Foundation Trust Barnsley PCT Bedfordshire PCT Blaenau Gwent Local Health Board Bradford & Airedale PCT Britannia Pharmaceuticals Limited British Association for Accident and Emergency Medicine British Association for Parenteral & Enteral Nutrition (BAPEN) British Association of Dermatologists, The British Association of Oral and Maxillofacial Surgeons British Association of Paediatric Surgeons British Association of Plastic Surgeons British Dermatological Nursing Group British Dietetic Association British Geriatrics Society British Geriatrics Society-Special Interest Group in Diabetes British Healthcare Trades Association British Hip Society (BHS) British Infection Society British National Formulary (BNF) British Nuclear Medicine Society British Orthopaedic Association British Paediatric Accident & Emergency Group British Psychological Society, The British Society for Antimicrobial Chemotherapy British Society of Rehabilitation Medicine Bromley Hospitals NHS Trust Buckinghamshire Acute Trust BUPA Calderdale PCT Cambridge University Hospitals NHS Foundation Trust Cardiff and Vale NHS Trust CASPE Research Changing Faces Chartered Society of Physiotherapy (CSP) Chronic Conditions Collaborating Centre Surgical site infection: full guideline DRAFT (April 2008) page v of 165 DRAFT FOR CONSULTATION City Hospitals Sunderland NHS Trust Clinical Effectiveness Committee Cochrane Wounds Group Coloplast Limited Commission for Social Care Inspection Community District Nurses Association Company Connecting for Health ConvaTec Conwy & Denbighshire Acute Trust Cornwall & Isles of Scilly PCT Coventry and Warwickshire Cardiac Network Covidien Department of Health Department of Health, Social Security and Public Safety of Northern Ireland Derbyshire Mental Health Services NHS Trust Diabetes UK Dudley Group of Hospitals NHS Trust East & North Herts PCT & West Herts PCT East and North Herts. NHS Trust English Community Care Association Enturia Ltd Faculty of Public Health Fibroid Network Charity Gloucestershire Acute Trust Good Hope Hospitals NHS Trust Gorlin Syndrome Group Health Protection Agency Healthcare Commission Heart of England Acute Trust Help the Aged Help the Hospices Hertfordshire Partnership NHS Trust Hill-Rom Hospital Infection Society Independent Healthcare Advisory Services Infection Control Nurses Association of the British Isles Institute of Biomedical Science Institute of Physics and Engineering in Medicine James Paget Healthcare NHS Trust Johnson & Johnson Medical KCI Medical Ltd. Kimberly-Clark Health Care Kimberly-Clark Health Care (UK) Kirklees Primary Care Trust Leeds PCT Leeds Teaching Hospitals NHS Trust Limbless Association Liverpool PCT Liverpool Women's NHS Trust Luton and Dunstable Hospital NHS Trust Maersk Medical Maidstone and Tunbridge Wells NHS Trust Medical Support Systems Limited Medicines and Healthcare Products Regulatory Agency (MHRA) Medihoney(Europe) Ltd Medlock Medical Medway NHS Trust Mental Health Collaborating Centre Mid Essex Hospitals NHS Trust Mid Staffordshire General Hospitals NHS Trust Surgical site infection: full guideline DRAFT (April 2008) page vi of 165 DRAFT FOR CONSULTATION Molnlycke Health Care MRSA Action UK NAASP Napp Pharmaceuticals National Council for Disabled People, Black, Minority and Ethnic Community (Equalities) National Nurses Nutrition Group National Patient Safety Agency National Public Health Service - Wales NCC for Cancer NCCHTA Neurological Alliance Newcastle PCT Newcastle Upon Tyne Hospitals NHS Foundation Trust NHS Direct NHS Quality Improvement Scotland NICE - Guidelines Coordinator - for info NICE - Guidelines