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Surgical Site Infection Surgical Site Infection National Collaborating Centre for Women’S and Children’S Health Surgical site infection Surgical site infection National Collaborating Centre for Women’s and Children’s Health Other NICE guidelines produced by the National Collaborating Centre for Women’s and Children’s Health include: • Antenatal care: routine care for the healthy pregnant woman • Fertility: assessment and treatment for people with fertility problems • Caesarean section • Type 1 diabetes: diagnosis and management of type 1 diabetes in children and young people • Long-acting reversible contraception: the effective and appropriate use of long-acting reversible contraception • Urinary incontinence: the management of urinary incontinence in women • Heavy menstrual bleeding • Feverish illness in children: assessment and initial management in children younger than 5 years • Urinary tract infection in children: diagnosis, treatment and long-term management • Intrapartum care: care of healthy women and their babies during childbirth • Atopic eczema in children: management of atopic eczema in children from birth up to the age of 12 years • Surgical management of otitis media with effusion in children • Diabetes in pregnancy: management of diabetes and its complications from preconception to the postnatal period Surgical site infection • Induction of labour Guidelines in production include: prevention and treatment of • Diarrhoea and vomiting in children under 5 prevention and treatment of • When to suspect child maltreatment • Hypertensive disorders in pregnancy • Neonatal jaundice surgical site infection • Constipation in children • Bacterial meningitis and meningococcal septicaemia in children • Pregnant women with complex social factors • Autism in children and adolescents • Multiple pregnancy Enquiries regarding the above guidelines can be addressed to: National Collaborating Centre for Women’s and Children’s Health King’s Court Fourth Floor 2–16 Goodge Street London W1T 2QA [email protected] Clinical Guideline October 2008 A version of this guideline for patients, carers and the public is available from the NICE website (www.nice.org.uk/CG074) or from NICE publications on 0845 003 7783; quote reference number N1702. Published by the Royal College of Obstetricians and Gynaecologists. Clinical Guideline To purchase further copies and for a complete list of RCOG Press titles, RCOG October 2008 RCOG Press Press visit: www.rcogbookshop.com 2008 Funded to produce guidelines for the NHS by NICE Surgical site infection prevention and treatment of surgical site infection National Collaborating Centre for Women’s and Children’s Health Commissioned by the National Institute for Health and Clinical Excellence October 2008 RCOG Press Published by the RCOG Press at the Royal College of Obstetricians and Gynaecologists, 27 Sussex Place, Regent’s Park, London NW1 4RG www.rcog.org.uk Registered charity no. 213280 First published 2008 © 2008 National Collaborating Centre for Women’s and Children’s Health No part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK [www.cla.co.uk]. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page. The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore for general use. While every effort has been made to ensure the accuracy of the information contained within this publication, the publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check current indications and accuracy by consulting other pharmaceutical literature and following the guidelines laid down by the manufacturers of specific products and the relevant authorities in the country in which they are practising. ISBN 978-1-904752-69-1 NCC-WCH Editor: Andrew Welsh Original design: FiSH Books, London Typesetting: Andrew Welsh Proofreading: Katharine Timberlake (Reedmace Publishing Ltd) Index: Jan Ross (Merrall-Ross (Wales) Ltd) Printed by Henry Ling Ltd, The Dorset Press, Dorchester DT1 1HD Contents Guideline Development Group membership and acknowledgements v Guideline Development Group v Acknowledgements v Stakeholder organisations vi Abbreviations xi Glossary of terms xii 1 Introduction 1 1.1 Surgical site infection 1 1.2 Aim of the guideline 3 1.3 Areas outside of the remit of the guideline 3 1.4 For whom is the guideline intended? 3 1.5 Who has developed the guideline? 3 1.6 Other relevant documents 4 1.7 Guideline methodology 4 1.8 Schedule for updating the guideline 7 2 Summary of recommendations 8 2.1 Key priorities for implementation (key recommendations) 8 2.2 Summary of recommendations 9 2.3 Key priorities for research 12 2.4 Summary of research recommendations 13 3 Definitions, surveillance and risk factors 15 3.1 Defining surgical site infection 15 3.2 Surveillance for surgical site infection 15 3.3 Risk factors 16 4 Information for patients and carers 21 4.1 Information for patients and carers 21 5 Preoperative phase 23 5.1 Preoperative showering 23 5.2 Hair removal 25 5.3 Patient theatre wear 28 5.4 Staff theatre wear 29 5.5 Staff leaving the operating area 30 5.6 Nasal decontamination 30 5.7 Mechanical bowel preparation 33 5.8 Hand decontamination (general) 35 5.9 Hand jewellery, artificial nails and nail polish 35 5.10 Antibiotic prophylaxis 36 6 Intraoperative phase 50 6.1 Hand decontamination 50 6.2 Incise drapes 51 6.3 Use of sterile gowns 53 6.4 Disposable or reusable drapes and gowns 54 6.5 Gloves 55 6.6 Antiseptic skin preparation 56 6.7 Diathermy 60 6.8 Maintaining patient homeostasis 62 6.9 Wound irrigation and intracavity lavage 66 6.10 Antiseptic and antimicrobial agents before wound closure 73 6.11 Closure methods 76 6.12 Wound dressings 86 iii Surgical site infection 7 Postoperative phase 91 7.1 Changing dressings 91 7.2 Postoperative cleansing 92 7.3 Topical antimicrobial agents for wound healing by primary intention 93 7.4 Dressings for wound healing by secondary intention 94 7.5 Antibiotic treatment of surgical site infection and treatment failure 97 7.6 Debridement 98 7.7 Specialist wound care services 99 Appendix A Declarations of interest 100 Appendix B Clinical questions 101 Appendix C Wound dressings for surgical site infection prevention 103 Appendix D Cost-effectiveness of hair removal 105 Appendix E Cost-effectiveness of mupirocin nasal ointment to prevent surgical site infection 110 caused by Staphylococcus aureus Appendix F Cost-effectiveness of closure methods 117 Appendix G Cost analysis of wound dressings 119 Appendix H General principles for hand hygiene (epic2) 122 Appendix I Postoperative cleansing of the wound 124 References 125 Index 133 Search strategies CD-ROM Excluded studies CD-ROM Evidence tables CD-ROM iv Guideline Development Group membership and acknowledgements Guideline Development Group GDG members Mark Collier Lead Nurse/Consultant – Tissue Viability David Evans Patient/carer member (Safety Engineer and Occupational Hygienist) Mark Farrington Consultant Medical Microbiologist Elizabeth Gibbs Patient/carer member (Teenage Pregnancy Specialist Midwife) Kate Gould Consultant Microbiologist (Clinical Advisor to the GDG) Helen Jenkinson Hygiene Code Implementation Manager Kathryn Kitson Team Leader for Orthopaedic and Trauma Theatres (stood down in December 2007 owing to work commitments) David Leaper GDG Chair, Visiting Professor, Department of Wound Healing Matt Thompson Professor of Vascular Surgery Jennie Wilson Infection Control Nurse/Programme Leader, Surgical Site Infection Surveillance Service 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 Coordinator Roxana Rehman Work Programme Coordinator Andrew Welsh Freelance copy-editor and typesetter 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 and Angela Kraut 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 of the Cochrane Wounds Group • Dr Roberta Jenkins at the Scottish Intercollegiate Guidelines Network (SIGN) • Dr Rosa Legood, Health Economist, London School of Hygiene & Tropical Medicine v Surgical site infection This guideline was developed from work initially undertaken by the National Collaborating Centre for Nursing and Supportive Care (NCC-NSC) and the members of the 2005 GDG, as part of an earlier NICE commission (http://www.nice.org.uk/guidance/index.jsp?action=byID&o=11622). GDG members (2005 consultation version) Una Adderley Tissue Viability Prescribing Specialist Nurse Mark Collier Lead Nurse/Consultant – Tissue Viability Christopher Dowson Professor of Microbiology
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