There are millions of microorganisms living on the skin, in the body and in the environment; they include bacteria, viruses and fungi.  Most of them cause no harm, but in the operating theatre during an open surgery, preventative measures are taken to avoid them at all costs.

Microorganisms from the skin or environment can enter the body through the surgical wound during or after the operation. They can multiply and cause an infection known as a surgical site infection (SSI) or a surgical wound infection.1 According to a study done by the NHS in 2015 and 2016 1,632 out of 136,872 procedures resulted in an SSI.2



Patient-Specific Risk Factors

Patient-specific risk factors can contribute to SSIs, and while some of these factors are modifiable, others are not.1 The following sections will provide more information about each of these risk factors and potential interventions to minimise these risks.


As patients age, they are more likely to have a number of comorbid conditions, an increased severity of acute illnesses and a decreased immune response to infection. Furthermore, older patients who develop SSIs have greater morbidity and mortality compared to younger patients who develop SSIs.2 Age is not a modifiable risk factor so it is important to adequately assess older patients preoperatively in order to gain a complete understanding of their baseline level of health and identify other risk factors that can be mitigated prior to surgery.

Nutritional State

A patient’s nutritional status greatly affects both his or her immune function and ability to heal. Malnutrition can decrease immune function and contribute to poor wound healing, both of which increase the susceptibility to infection. If a patient is found to be malnourished preoperatively, appropriate interventions should be planned to improve the patient’s nutritional status prior to surgery.3


Obesity-related immune dysregulation, decreased cell-mediated immune responses, obesity-related comorbidities such as diabetes, respiratory issues and pharmacologic issues are all factors that contribute to the overall mechanism of increased susceptibility to SSIs.4 It is important to preoperatively assess the BMI of obese patients and to encourage weight loss and proper nutrition prior to surgery.

Diabetes Mellitus and Hyperglycaemia

Studies have shown that both insulin-dependent and non-insulin-dependent diabetic patients are at an increased risk for developing SSIsbecause of depressed immune function and delayed wound healing. Diabetic patients need to have strictly controlled blood glucose levels preoperatively, intraoperatively and postoperatively. Patients should receive insulin perioperatively to control hyperglycaemia and minimise the risk of adverse outcomes.6

Bacterial Colonisation and Coexisting Infections

Research shows that surgical sites containing more than 100,000 microorganisms per gram of tissue have a significantly greater risk of infection. However, it is important to note that the number of microorganisms necessary to cause an infection is significantly lower when there is foreign material such as surgical mesh at the site.7 If a patient has an existing infection at the time of surgery, this also increases the likelihood of developing an SSI.1

Smoking and Nicotine Use

Smoking reduces oxygen delivery to tissues, impairing wound healing and immune defences. Smoking cessation prior to surgery can help increase oxygenation to the tissues, improve healing and reduce the risk of SSIs. Supplemental oxygen perioperatively can also help improve tissue oxygenation and reduce SSI risk.8


Any medical conditions or medications that cause immunosuppression will increase the risk of SSIs. In particular, steroids have been linked with increased postoperative complications.9

1 Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. American Journal of Infection Control. 1999 Apr; 27(2): 97-132
2 McGarry S, Engemann J, Schmader K, Sexton DJ, Kaye KS. Surgical Site Infection due to Staphylococcus Aureus in the Elderly: Mortality, Duration of Hospitalization and Cost. Infection Control & Hospital Epidemiology. 2004 Jun; 25(6): 461-467
3 Culebras JM. Malnutrition in the Twenty-First Century: An Epidemic Affecting Surgical Outcome. Surgical Infections. 2013 Jun; 14(3): 237-243
4 Huttunen R, Syrjänen J. Obesity and the Risk and Outcome of Infection. International Journal of Obesity. 2013 May; 37: 333-340
5 Ashar A, Valerian BT, Lee EC, Bestle SL, Elmendorf SL, Stain SC. The Effect of Diabetes Mellitus on Surgical Site Infections after Colorectal and Noncolorectal General Surgical Operations. The American Surgeon. 2010 Jul; 76(7): 697-702
6 Kwon S, Thompson R, Dellinger P, Yanez D, Farrohki E, Flum D. Importance of Perioperative Glycemic Control in General Surgery: A Report from the Surgical Care and Outcomes Assessment Program. Annals of Surgery. 2013 Jan; 257(1): 8-14
7 Krizek TJ, Robson MC. Evolution of Quantitative Bacteriology in Wound Management. Am J Surg. 1975 Nov; 130(5): 579-84
8 Belda FJ, Aguilera L, García de la Asunción J, Alberti J, Vicente R, Ferrándiz L, Rodríguez R, Company R, Sessler DI, Aguilar G, Botello SG, Ortí R; Spanish Reduccion de la Tasa de Infeccion Quirurgica Group. Supplemental Perioperative Oxygen and the Risk of Surgical Wound Infection: A Randomized Controlled Trial. JAMA. 2005 Oct 26;294(16):2035-42. Erratum in: JAMA. 2005 Dec; 294(23):2973.
9 Ismael H, Horst M, Farooq M, Jordon J, Patton JH, Rubinfeld IS. Adverse Effects of Preoperative Steroid Use on Surgical Outcomes. American Journal of Surgery. 2011 Mar; 201(3):305-8

Preoperative Risk Factors for SSI Development

Numerous factors can affect SSI risk prior to surgery. The following sections will discuss ways to address these risk factors in order to enhance patient safety and improve outcomes.1

Antimicrobial Prophylaxis

If prophylactic antibiotics are needed, they should be administered within one hour before skin incision and discontinued within 24 hours after the surgery ends. Antibiotics continued for treatment of a specific infection are the exception to this rule.2

Preoperative Hair Removal

Shaving is an inappropriate method of hair removal because it can result in multiple skin abrasions, which can later become infected.2 Hair should only be removed if it will interfere with the operation, by using clippers or a depilatory agent.

Preoperative Skin Preparation and Antisepsis

The goal of preoperative skin preparation and antisepsis is to clean the skin and remove microorganisms, reducing the SSI risk.3 The Association of periOperative Registered Nurses (AORN) recommends that patients should shower prior to surgery with either soap or an antiseptic.3 Multidisciplinary teams, including perioperative nurses, physicians and infection prevention specialists, should select safe and effective products for preoperative skin antisepsis. The solution used for each patient and each procedure should meet regulations and be appropriate for the patient and his or her specific needs, such as allergies or sensitivities.3

Prior to applying the antiseptic preparation solution to the patient’s skin, the nurse should assess the skin integrity at the surgical site. It should be free of any soil, debris, emollients, cosmetics and alcohol-based products. Nurses should perform hand hygiene, don sterile gloves and use sterile technique while applying the skin antiseptic. Once the skin has been prepared, only sterile items should be exposed to the skin.3

Sterile Attire

Personnel in the perioperative area should adhere to appropriate guidelines for sterile attire to minimise the patients’ exposure to microorganisms. AORN provides best-practice recommendations for surgical attire:

  1. Clean surgical attire should be worn in the semi-restricted and restricted areas of the perioperative setting.
  2. All individuals who enter the semi-restricted and restricted areas should wear scrub attire that has been laundered at a healthcare-accredited laundry facility or disposable scrub attire intended for use within the perioperative setting.
  3. Personnel entering the semi-restricted and restricted areas should cover their head, hair, ears and facial hair.

1 Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. American Journal of Infection Control. 1999 Apr; 27(2): 97-132
2 Specifications Manual for Joint Commission National Quality Core Measures (2010A1). (2010). Retrieved 23/06/2015 from
3 Conner R (Ed.). Guidelines for Perioperative Practice: 2015 Edition. AORN, Inc. 2015

Intraoperative Risk Factors

Intraoperative risk factors comprise the surgical technique used, including adequacy of haemostasis, quality of wound closure, tissue trauma and wound management, the presence of foreign material in the surgical site, the presence of surgical drains, adherence to sterile technique, adequacy of instrument sterilisation, operating theatre ventilation, perioperative hypothermia, adequacy of oxygenation and the length and type of operation.1

Surgical Technique

Surgical technique can vary widely from surgeon to surgeon and can greatly influence the development of SSIs. The surgical technique encompasses numerous activities performed during the surgery. Here are a few techniques that can help minimise the risk of postoperative infection:

  • Achieving adequate haemostasis while simultaneously preserving blood supply to the tissues
  • Handling tissues gently
  • Avoiding inadvertent perforation of a hollow viscus such as the stomach
  • Removing devitalised tissues that are charred or necrotic, for example
  • Properly utilising drains and suture material and minimising dead space
  • Preventing intraoperative hypothermia1

Foreign Material in the Surgical Site

Foreign materials within the surgical site present a nidus for infection. There are a wide variety of foreign materials, ranging from suture material to surgical mesh, or prostheses. They can promote inflammation and bacteria can grow on them.1

Surgical Drains

Surgical drains are an example of foreign materials that can potentially increase a patient’s risk of an SSI, particularly if the drains are not handled properly. When drains are placed through an operative incision, the likelihood that an SSI will develop is higher. Drains should be placed through a separate incision distant from the surgical incision site to minimise this risk. Additionally, studies have shown that when drains are placed to closed suction rather than open, the incidence of SSI is reduced. The utilisation of drains can be important postoperatively and can help effectively evacuate hematomas or seromas, which could also become infected. However, it is important to keep in mind that the timing of drain removal can also affect infection rates. Bacterial colonisation of the drain tract will increase the longer the drain is left in place.1

Adherence to Sterile Technique

Sterile technique is a process that employs specific actions to prevent contamination and maintain a sterile field during procedures. This includes wearing clean scrub attire, including appropriate head and feet coverings, following hand hygiene practices and wearing a clean mask for each procedure. A well-maintained sterile field can influence patient outcomes and reduce infection rates.2

Instrument Sterilisation

Inadequate instrument sterilisation has been associated with SSI outbreaks. It is therefore important to understand different methods of sterilisation and the guidelines in place for ensuring the efficacy of the sterilisation process. There are different methods of sterilisation; these include steam under pressure, dry heat, ethylene oxide and gamma radiation.1

Operating Theatre Ventilation

The air in the operating theatre may contain dust, lint, skin squames or respiratory droplets, which are laden with microorganisms. The number of microbes in the air is related to the traffic in and out of the operating theatre; therefore, traffic should be limited. Additionally, operating theatres should maintain positive pressure compared to adjacent areas. This prevents airflow from the adjacent areas, which are presumably less clean, into the operating theatre.1

Perioperative Hypothermia

Many different studies have shown that patients who are hypothermic in the perioperative period have increased rates of postoperative complications including SSIs. Hypothermia is defined as a core body temperature of less than or equal to 36o Celsius. In the cold operating theatre environment, the body pushes blood away from the skin into the core of the body to protect vital organs, resulting in decreased perfusion and oxygenation of the skin. Blood vessels in the skin also undergo vasoconstriction, further reducing blood flow. Furthermore, when the body temperature is low, cellular consumption of oxygen is reduced. This reduction in perfusion and oxygenation impairs the natural defences within the skin from being able to adequately fight infectious organisms.3


Adequate oxygen supply to tissues is essential for wound healing and infection prevention. Oxidative killing, or destruction by oxidation, is the most important mode of defence against pathogenic organisms. This process is dependent upon the partial pressure of oxygen in the tissue.4

Length and Type of Operation

Both the length and type of procedure can affect the patient’s risk of developing an SSI. Longer procedures are associated with a higher SSI risk. Different types of procedures have varying levels of contamination, which directly affect SSI risk.

1 Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. American Journal of Infection Control. 1999 Apr; 27(2): 97-132
2 Conner R (Ed.). Guidelines for Perioperative Practice: 2015 Edition. AORN, Inc. 2015
3 Wagner VD. Patient Safety Chiller: Unplanned Perioperative Hypothermia. AORN Journal. Nov 2010; 92(5): 567-571
4 Greif R, Akca O, Horn EP, Kurz A, Sessler DI. Supplemental Perioperative Oxygen to Reduce the Incidence of Surgical-Wound Infection. New England Journal of Medicine. 2000 Jan; 342: 161-167

Postoperative Risk Factors

Risk factors for SSIs are not limited to preoperative and operative determinants. Postoperative factors can also affect SSI development.1

Types of Wound Closure

Postoperative wound care can vary greatly depending on the type of wound and how it is closed. Primary closure, also known as healing by primary intention, describes fully closing the surgical wound in the operating theatre, either with staples or sutures. Secondary closure, or healing by secondary intention, occurs when the wound edges are not initially approximated in the operating theatre. Granulation tissue gradually fills in the wound defect, healing the wound. Delayed primary closure, also known as healing by tertiary intention, happens when the surgical wound is left open following the surgery, but is then closed after a few days of observation if no infection is present.
Both secondary closure and delayed primary closure are used when the wound is thought to be contaminated.2

Incision Care

Wound care is unique to the wound type and how it is closed. Most surgical wounds are closed primarily.
These wounds are typically covered with a sterile dressing for 24 to 48 hours. This allows epithelialisation of the wound to occur, which is thought to protect the wound from infectious pathogens from the outside. After this period, dressings can be quite variable, and often, no dressings are used at all. Dressings should be applied based on the condition of and drainage from the wound. When delayed primary closure or secondary closure techniques are used, the wound is initially packed with sterile gauze and is covered with a sterile dressing. The rationale behind these techniques is that the wound is likely contaminated; therefore, it should be left open, as to not trap the bacteria. These wounds should be closely monitored for signs of infection.1

Length of Hospital Stay

An overall increase in the length of hospital stay increases the risk of SSIs. The longer patients are hospitalised, the more exposure they have to bacteria found in a hospital, particularly antibiotic-resistant bacteria.1

Discharge Planning and Instructions

Patients are regularly discharged before their wounds have fully healed. Therefore, thorough discharge instructions for appropriate wound care are needed. Nurses and other members of the healthcare team should ensure that patients understand exactly how to care for their wounds. Patients should also be encouraged to contact their surgeon’s team with any questions.1

1 Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. American Journal of Infection Control. 1999 Apr; 27(2): 97-132
2 Myers BA. (2008). Wound management principles and practice 2nd ed. Upper Saddle River, NJ: Pearson

Medline Solutions for SSI Prevention

Cleaning in preparation for surgery combined with skin disinfection are two necessary steps for the initial reduction of surface bacteria and SSI prevention. However, the amount of skin microorganisms is reduced, but not eliminated, and they can survive in microscopic folds of the skin. 

Dermadine® Impregnated Incise Drape

When the skin is cleaned and long-lasting asepsis is required, the Dermadine incise drape guarantees that a sterile field is maintained. Its broad spectrum of antimicrobial activity against the skin’s microorganisms makes this possible, thus reducing the risk of SSIs. The Dermadine incise drape provides a constant iodine presence for more than 24 hours, helping reduce the risk of skin flora contaminating the open wound. 

measurement of antibacterial activity

Fast Acting

When applied, the Dermadine incise drape demonstrates strong antimicrobial activity. There is a significant reduction in the bioburden within 30 minutes of application. Dermadine guarantees constant asepsis on the patient’s skin, even for long periods of time.

Conformable and Enveloping

Dermadine is naturally elastic and ultra-thin, ensuring a perfect fit and conformation to anatomical structures and joints. It adapts to large muscle deformations (even when autostatic retractors are used) without losing its adhesive properties.

Breathable, Water-Repellent and Waterproof

Dermadine combines blood and water repellence with water vapour breathability to prevent the formation of fluid collection, which can reduce adhesiveness over long periods of time. The breathable film guarantees complete impermeability to microorganisms.

Strong and Anti-Glare 

In addition to its excellent resistance to tearing, Dermadine also allows for easy surgical incision with any scalpel blade and provides indirect protection from tearing for thin skin. Its anti-glare properties provide perfect visibility at the point of incision under the presence of reflected light.

Adhesion with the Presence of an Antimicrobial Agent

The skin-friendly medical adhesive allows for high-peel adhesion on all types of skin surfaces and especially around the wound’s edges, without any skin irritation. The polyacrylic structure in Dermadine’s adhesive contains an iodophor complex. A surfactant J-carrier transports iodine and begins releasing it upon application to the skin. The acrylic adhesive is atraumatic during detachment, even on elderly patients’ skin, and guarantees no residual adhesive after removal.

Dermadine is a sterile class IIa medical device intended to be used by healthcare professionals. Before use, consult instructions and precautions on the corresponding labelling.
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