Doctor and surgical nurses during an operation

Prevention of surgical site infection (SSI)

Surgical Site Infections –
The history of prevention

Every medical procedure is accompanied by a risk of infection. Preventive measures in particular are key to avoiding postoperative wound infections. Since 1983, health authorities have published recommendations with behavioural guidelines, for example, what steps are important and when they should be taken.

“The very first requirement in a hospital is that it should do the sick no harm.” Florence Nightingale (1820-1910) stated this already in the century before last. The British nurse influenced medical care and health care like almost no other at the time. Today the topic is more relevant than ever. The prevention of Surgical Site Infections (SSI) has become increasingly important, especially as the number of surgical procedures continues to rise1. In Germany, for example, the number of operations increased by 39 per cent between 2005 and 2016 (see chart), as annual evaluations by the German Federal Statistical Office show2.

The demands on the reporting of quality indicators on the one hand, combined with patient and employee protection on the other hand, continue to grow. In addition, patients who need surgery tend to be older today, and often suffer from serious surgery-related secondary diseases3.

Number of surgeries in Germany 2005-2016

SSI are among the most common hospital acquired infections

With a share of approximately 22 per cent, SSI are the second most common nosocomial infections in
Germany4. Although in high-income countries the overall SSI rate is somewhat lower, it remains the second most common form of nosocomial infection in Europe and the USA. In low and middle-income countries, SSI is the most common form of nosocomial infection, according to the WHO.

But this fact shouldn’t be simply accepted. Proper infection prevention can drastically reduce the risk of infection for patients. Clearly formulated and practical guidelines are the basis for implementing proven and effective infection prevention measures. That is why the health authorities have long relied on such guidelines.

SSI prevention recommendations since 1983

In the USA, the Centers for Disease Control and Prevention (CDC) published the first recommendations for the prevention of SSI5 in 1983, when the CDC was still known as the Office of National Defense Malaria Control Activities (founded in 1946 to support the control of malaria). This first guideline covered only the prevention of intraoperative wound infections. The 1985 reissue added new information on preoperative hair removal and surgical ventilation. The 1999 version first coined the term “Surgical Site Infections”.

At global level, WHO formulated its first guidelines for the prevention of SSI on 3 November 2016.6 These guidelines contained a list of 29 specific recommendations compiled by 20 of the world’s leading experts from 26 review publications. The recommendations were published in “The Lancet Infectious Diseases” journal and are intended to counteract the increasing risk of healthcare infections for both patients and healthcare systems worldwide. Since then, WHO has regularly updated the guidelines to incorporate the latest scientific findings.

Latest KRINKO recommendation from April 2018

This is also the goal of the Commission for Hospital Hygiene and Infection Prevention (KRINKO) at the Robert Koch Institute, whose latest recommendation on “Prevention of postoperative wound infections” dates from April 2018. KRINKO’s hygiene experts are continually developing the guidelines further, under consideration of current infection epidemiological evaluations. The guidelines are drawn up in accordance with the Infection Protection Act (IfSG) § 23 and published by the German Robert Koch Institute (RKI) in the Federal Health Gazette.

The current new edition became necessary “because more than 15 years had passed since the first edition of the ‘Hygiene requirements for operations and other invasive procedures’,” the authors explain. In addition, with continued development of invasive treatments, it has become increasingly difficult to distinguish between these and operations in the classical sense. And “finally, from the aspect of infection prevention, special treatment of outpatient operations – based only on the attribute ‘outpatient’ – lacks justification”.7

patient in hospital bed

Interventions in detail

Pre- and intraoperative procedures include the following:

• As far as possible, identify and preoperatively treat existing infections in the patient.
• In certain operations in patients with nasal colonisation with S. aureus, perform preoperative nose decolonisation with Mupirocin nasal ointment two per cent, alone or in combination with a body wash containing chlorhexidine gluconate.
• Keep the preoperative stay as short as possible.
• Shorten hair in the surgical area and do not remove it by shaving.
• Before entering the operating area, personnel must leave all of their outer garments, including shoes, in the personnel changing room. In the clean area, following hygienic hand disinfection, they must put on low-germ clothing.
• Do not wear jewellery, rings or watches on wrists and hands, nor other pieces of jewellery, artificial fingernails or nail polish, as these all present a contamination risk.
• Apply mouth and nose protection (MNP)° and hair protection before entering the operating theatre. Replace these before each operation and in case of visible soiling or moisture penetration.
• Enter the operating room with clean hands. After washing your hands, dry them before surgical hand disinfection.
• The surgical team, including the instrumentation staff, must perform surgical hand disinfection.
• Wear sterile surgical gowns° and sterile gloves. Wear two pairs of gloves during types of surgery that are commonly associated with an increased lesion of gloves.
• Perform a thorough antisepsis of the skin of the surgical area with an alcohol-based skin antiseptic in the operating theatre.
• The area surrounding the operation area must be covered and sterile°.
• Use only appropriately prepared medical devices.
• After each operation, disinfect the areas near the patient, all visibly contaminated areas and the entire floor of the operating theatre.
• In the washing zones, disinfect the taps used and the wash-up sinks at regular intervals. In the other ancillary rooms, initiate disinfectant cleaning in the event of visible soiling.
• In the case of contamination with bacterial spores or non-enveloped viruses, choose agents with sporicidal or virucidal activity.

Recommended postoperative measures include, among others:

• Cover the surgical wound with a sterile dressing at the end of the operation. The first dressing change should be performed after about 48 hours, unless there are indications of complications leading to an earlier dressing change.
• In addition to providing the patient with the necessary information about the risks associated with the operation, offer basic instruction on ways to prevent SSI through hygiene-conscious behaviour, as well as information in advance on signs of unhealthy healing processes.

The complete list can be found here in German.

The KRINKO guideline in the version of 2018 replaces and summarises previous recommendations, including the recommendations for the prevention of postoperative infections in the operating area7 (previous version from 20078), the requirements of hygiene during operations and other invasive interventions (version from 2000) and the requirements of hygiene during outpatient operations in hospitals and practices (version from 1997).

The spectrum of pathogens varies depending on the type of operation

Nosocomial postoperative wound infections are usually caused by bacterial pathogens, and on occasion combined with fungi. The pathogen spectrum can vary depending on the surgical region or type of operation. According to the KRINKO guideline, hygienic behaviour, accompanying pre-, intra- and postoperative measures as well as spatial and structural requirements complement each other in the prevention of SSI. According to the authors, the question of whether an “outpatient” or “inpatient” operation is performed plays no role in assessing the SSI risk.

The bacteria most frequently associated with SSI include:

Staphylococcus aureus
Enterococcus spec
Escherichia coli
Koagulase-negative Staphylococci
Pseudomonas aeruginosa

Experts agree that it will not be possible to reduce the infection rate to zero. However, up to 40 per cent of all nosocomial infections could be prevented through proper hand hygiene alone9. Participation in a national surveillance system (NNIS) and feedback from one’s own SSI data with national reference data can also reduce the infection rate by 25-65 per cent. This has been shown by data from surveillance systems in various countries7,10. These figures show that the effort is worthwhile. This helps to bring Florence Nightingale’s aspiration for a hospital that does no harm to patients a good deal closer.


  1. Operationen in Kranken­häusern: Plus von 30 % zwischen 2005 und 2013, Statistisches Bundesamt (Destatis)

  2. Gesundheit – Grunddaten der Krankenhäuser, Statistisches Bundesamt (Destatis)

  3. Global Burden of Disease, The Lancet

  4. Deutsche nationale Punkt-Prävalenzerhebung zu nosokomialen Infektionen und Antibiotika-Anwendung 2016 – Abschlussbericht, Nationales Referenzzentrum für Surveillance von nosokomialen Infektionen

  5. Guidelines for prevention of surgical wound infection, Polk HC Jr et al., Arch Surg.

  6. Global guidelines on the prevention of surgical site infection, World Health Organization

  7. Prävention postoperativer Wundinfektionen – Empfehlung der Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO) beim Robert Koch-Institut, Robert Koch-Institut

  8. Prävention postoperativer Infektionen im Operationsgebiet – Empfehlung der Kommission für Krankenhaushygiene und Infektionsprävention beim Robert Koch-Institut, Robert Koch-Institut

  9. Händehygiene zur Prävention nosokomialer Infektionen, Kampf G et al., Dtsch Arztebl Int 2009

  10. Reduction of surgical site infection rates associated with active surveillance, Brandt C et al., Infect Control Hosp Epidemiol.

    °commercial communication

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