Updated Recommendations for Control of Surgical Site Infections

J. Wesley Alexander, MD, ScD; Joseph S. Solomkin, MD; Michael J. Edwards, MD


Annals of Surgery. 2011;253(6):1082-1093. 

In This Article

Preoperative Bathing with Antiseptic Agents

Infections in clean surgery are most often caused by skin organisms and, consequently, there have been several approaches to decrease the number of bacteria colonizing the skin before patients come to the operating room. It is important, however, to note that organisms in sebaceous and other glands and hair follicles are not exposed to topical antiseptics. Bathing with hexachlorophene was shown to decrease wound infections in several studies before 1970 (SDC-14), but because chlorhexidine provided better long-term suppression of organisms than hexachlorophene, it soon became the agent of choice. In a study of groin wounds in vascular surgery, the wound infection rate was decreased from 17.8% to 8% when patients showered 3 to 8 times preoperatively with chlorhexidine (SDC-15). Preoperative showering with chlorhexidine has been shown to reduce the number of organisms at the incision site better than using povidone iodine or soap and water (SDC-16–17). Using a shower the evening before and the morning of an operation is more effective in colony reduction than a single shower either the night before or the morning of operation (SDC-18). Additional use of a cloth impregnated with chlorhexidine is more effective than simple showering. However, despite repeated demonstrations of a reduction in surface bacteria at the operative site using a chlorhexidine shower, recent meta-analyses have shown only a nonsignificant reduction in wound infections in large numbers of patients (SDC-19-22).

In a recent randomized trial examining MRSA detection/nasal decontamination/hexa-chlorophene showers, the significant reduction in infections seen was attributed to both treatments (SDC-23). It is well known that the nasal carriers are likely to have extranasal sites that are contaminated with the same strain and that carriers are at increased risk for endogenous S. aureus infections (SDC-24–25). The authors suggest that the use of chlorhexidine for simultaneous elimination of S. aureus from extranasal sites is needed to achieve the level of prohylaxis observed in this trial. Although this additional precaution might not lead to complete eradication of the organism, bacterial loads would probably be sufficiently reduced to prevent infection (SDC-26).


Preoperative bathing with chlorhexidine reduces pathogenic organisms on the skin but has a nonsignificant reduction in wound infections. The demonstration that a more substantial reduction of skin organisms using multiple showers or showers immediately before coming to the operating room suggests that timing might explain lower effectiveness in some of the reports. Cleansing with a cloth impregnated with chlorhexidine just before operation will provide additional removal of dirt and further reduction in skin bacteria.


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