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Wound infections after an operation are common and mostly preventable. Before surgery you shower, hair is clipped rather than shaved if it has to go, a single dose of antibiotic is given shortly before the cut when the operation needs it, and the skin is cleaned with chlorhexidine in alcohol. You are kept warm during the operation, and the wound is covered and cared for cleanly afterwards.
NICE NG125 (2019, updated 2020) and the WHO global guidelines (2nd edition, 2018) agree on the core. Shower or bathe with soap before surgery (WHO conditional, moderate quality: plain or antimicrobial soap). Do not remove hair routinely; if needed, use clippers, never razors (WHO strong, moderate). Give antibiotic prophylaxis for clean-contaminated and contaminated operations and implants, before incision (WHO strong, low quality) and within 120 minutes of it (WHO strong, moderate), repeating it if the operation outlasts the drug's half-life; do not continue it after the operation (WHO strong, moderate) or because a drain is in place (WHO conditional, low). Prepare the skin with alcohol-based chlorhexidine (WHO strong, low to moderate; NICE first choice unless next to a mucous membrane). Keep the patient warm, consider triclosan-coated sutures (both), and cover the wound at the end of the operation; shower after 48 hours (NICE).
They differ in places. On oxygen, WHO suggests 80% inspired oxygen during and for 2 to 6 hours after intubated general anaesthesia (conditional, moderate), while NICE asks for enough oxygen to keep saturation above 95%. For elective colorectal surgery, WHO suggests oral antibiotics combined with mechanical bowel preparation (conditional, moderate) and recommends against bowel preparation alone (strong, moderate); NICE says not to use mechanical bowel preparation routinely and does not address oral antibiotics. On wound irrigation, NICE says do not irrigate, while WHO suggests considering aqueous povidone-iodine irrigation (conditional, low). WHO suggests prophylactic negative pressure dressings on high-risk closed wounds (conditional, low); NICE NG125's recommendations do not mention them. Nasal mupirocin for Staphylococcus aureus carriers is recommended by WHO for cardiothoracic and orthopaedic surgery (strong) and suggested for others; NICE leaves it to local decision.
Why: People who know the signs of infection come back early, when it is easier to treat.
“Offer patients and carers information and advice about how to recognise a surgical site infection and who to contact if they are concerned.”
NICE 2019 · [2008]
Why: Washing lowers the number of germs on the skin; plain soap works as well as antiseptic soap in the trials WHO reviewed.
“It is good clinical practice for patients to bathe or shower prior to surgery. The panel suggests that either a plain or antimicrobial soap may be used for this purpose.”
World Health Organization 2018 · Conditional recommendation, moderate quality of evidence
Why: Shaving makes tiny cuts in the skin where germs grow.
“The panel recommends that in patients undergoing any surgical procedure, hair should either not be removed or, if absolutely necessary, it should be removed only with a clipper. Shaving is strongly discouraged at all times, whether preoperatively or in the operating room (OR).”
World Health Organization 2018 · Strong recommendation, moderate quality of evidence
Why: The antibiotic needs to be in the tissues when the skin is cut; given too early or after the cut, it protects less.
“The panel recommends the administration of SAP within 120 minutes before incision, while considering the half-life of the antibiotic.”
World Health Organization 2018 · Strong recommendation, moderate quality of evidence
Why: A long operation can outlast the protection of one dose.
“Give a repeat dose of antibiotic prophylaxis when the operation is longer than the half-life of the antibiotic given.”
NICE 2019 · [2008]
Why: Chlorhexidine in alcohol kills skin germs best; alcohol left pooled or wet can catch fire with diathermy.
“The panel recommends alcohol-based antiseptic solutions based on CHG for surgical site skin preparation in patients undergoing surgical procedures.”
World Health Organization 2018 · Strong recommendation, low to moderate quality of evidence
Why: Even mild cooling reduces blood flow to the wound and the body's defences against infection.
“The panel suggests the use of warming devices in the operating room and during the surgical procedure for patient body warming with the purpose of reducing SSI.”
World Health Organization 2018 · Conditional recommendation, moderate quality of evidence
Why: Sutures coated with an antiseptic reduce infection a little across many types of surgery.
“The panel suggests the use of triclosan-coated sutures for the purpose of reducing the risk of SSI, independent of the type of surgery.”
World Health Organization 2018 · Conditional recommendation, moderate quality of evidence
Why: A clean covering protects the wound while it seals over in the first days.
“Cover surgical incisions with an appropriate interactive dressing at the end of the operation.”
NICE 2019 · [2008]
Why: Continuing antibiotics does not prevent more infections and adds side effects and resistance.
“The panel recommends against the prolongation of SAP administration after completion of the operation for the purpose of preventing SSI.”
World Health Organization 2018 · Strong recommendation/moderate quality of evidence
Why: After two days a closed wound is sealed enough to get wet.
“Advise patients that they may shower safely 48 hours after surgery.”
NICE 2019 · [2008]
Why: Early treatment stops a wound infection spreading or opening the wound.
“When surgical site infection is suspected by the presence of cellulitis, either by a new infection or an infection caused by treatment failure, give the patient an antibiotic that covers the likely causative organisms.”
NICE 2019 · [2008]
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
Soap shower, no shaving (clippers if needed), timed single-dose antibiotic prophylaxis before incision and within 120 minutes, alcohol-based chlorhexidine skin preparation, active warming, triclosan-coated sutures considered, no prophylaxis after the operation ends, a dressing at closure and showering from 48 hours (WHO 2018 and NICE NG125 agree; WHO grades as listed). Where they disagree, both are shown: inspired oxygen 80% (WHO, conditional, moderate) against saturation above 95% (NICE); oral antibiotics with bowel preparation before elective colorectal surgery (WHO, conditional, moderate) against no routine bowel preparation (NICE, which does not address oral antibiotics); povidone-iodine wound irrigation considered (WHO, conditional, low) against no irrigation (NICE); prophylactic negative pressure dressings on high-risk wounds (WHO, conditional, low), which NICE NG125's recommendations do not mention.
Where it differs: Gives 80% oxygen through the breathing tube during surgery and, where feasible, for 2 to 6 hours afterwards, rather than enough to keep saturation above 95%.
Evidence: WHO conditional recommendation, moderate quality of evidence. NICE asks only for saturation above 95% during major surgery and recovery.
Where it differs: Gives oral antibiotics together with bowel preparation the day before elective colorectal cancer surgery.
Evidence: WHO suggests the combination (conditional, moderate quality) and recommends against bowel preparation alone (strong, moderate). NICE NG125 (2008 wording) says not to use mechanical bowel preparation routinely and does not mention oral antibiotics.
Where it differs: Washes the incision with aqueous povidone-iodine before closing, particularly in clean and clean-contaminated wounds.
Evidence: WHO conditional, low quality of evidence; WHO found insufficient evidence for or against saline irrigation and suggests against antibiotic irrigation. NICE says not to use wound irrigation to reduce SSI, and to apply antiseptics or antibiotics to the wound before closure only within a trial.
Where it differs: Puts a negative pressure (vacuum) dressing on a closed high-risk incision.
Evidence: WHO conditional, low quality of evidence, taking resources into account. NICE NG125's recommendations do not mention it.
Where it differs: Treats known nasal carriers of S. aureus with mupirocin ointment, with or without a chlorhexidine body wash, around surgery.
Evidence: WHO recommends it for cardiothoracic and orthopaedic surgery (strong, moderate) and suggests considering it for other surgery (conditional, moderate). NICE says consider it where S. aureus is a likely cause, decided locally, with resistance surveillance.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Antibiotic prophylaxis before incision when indicated “The panel recommends the administration of SAP prior to the surgical incision when indicated (depending on the type of operation).” | Strong recommendation, low quality of evidence | World Health Organization 2018 |
| Antibiotic prophylaxis within 120 minutes before incision | Strong recommendation, moderate quality of evidence | World Health Organization 2018 |
| Alcohol-based chlorhexidine for skin preparation | Strong recommendation, low to moderate quality of evidence | World Health Organization 2018 |
| No shaving; clippers only if hair must be removed | Strong recommendation, moderate quality of evidence | World Health Organization 2018 |
| No prolongation of prophylaxis after the operation | Strong recommendation/moderate quality of evidence | World Health Organization 2018 |
| Prophylaxis not continued because a drain is present “The panel suggests that perioperative antibiotic prophylaxis should not be continued to the presence of a wound drain for the purpose of preventing SSI.” | Conditional recommendation, low quality of evidence | World Health Organization 2018 |
| 80% inspired oxygen during intubated general anaesthesia and 2 to 6 hours after “The panel suggests that adult patients undergoing general anaesthesia with tracheal intubation for surgical procedures should receive an 80% fraction of inspired oxygen (FiO2) intraoperatively and, if feasible, in the immediate postoperative period for 2-6 hours to reduce the risk of SSI.” | Conditional recommendation, moderate quality of evidence | World Health Organization 2018 |
| Oral antibiotics with mechanical bowel preparation in elective colorectal surgery “The panel suggests that preoperative oral antibiotics combined with mechanical bowel preparation (MBP) should be used to reduce the risk of SSI in adult patients undergoing elective colorectal surgery.” | Conditional recommendation, moderate quality evidence | World Health Organization 2018 |
| No mechanical bowel preparation alone in elective colorectal surgery “The panel recommends that MBP alone (without administration of oral antibiotics) should not be used for the purpose of reducing SSI in adult patients undergoing elective colorectal surgery.” | Strong recommendation, moderate quality evidence | World Health Organization 2018 |
| Prophylactic negative pressure wound therapy on high-risk closed incisions “The panel suggests the use of prophylactic negative pressure wound therapy (pNPWT) in adult patients on primarily closed surgical incisions in high-risk wounds, for the purpose of the prevention of SSI, while taking resources into account.” | Conditional recommendation, low quality of evidence | World Health Organization 2018 |
| Do not use wound irrigation to reduce SSI “Do not use wound irrigation to reduce the risk of surgical site infection.” | [2008] (NICE does not grade) | NICE 2019 |
| Maintain oxygen saturation above 95% during major surgery and recovery “Maintain optimal oxygenation during surgery. In particular, give patients sufficient oxygen during major surgery and in the recovery period to ensure that a haemoglobin saturation of more than 95% is maintained.” | [2008] (NICE does not grade) | NICE 2019 |