Guidelines Key Takeaways for Patient Skin Antisepsis

The goal of preoperative patient skin antisepsis is to reduce the patient’s risk of developing an SSI by removing soil and transient microorganisms at the surgical site. Reducing bacteria on the skin near the surgical incision lowers the risk of contaminating the incision site.As part of preparing the skin for antisepsis, preoperative decolonization, preoperative bathing, and hair management at the surgical site contribute to a reduction of microorganisms.Effective skin antiseptics rapidly and persistently remove transient microorganisms and reduce resident microorganisms with minimal skin and tissue irritation.

Why is surgical site preparation important?

The purpose of surgical site preparation before beginning a procedure is to reduce the microbial load on the patient’s skin and inhibit rapid rebound growth of microorganisms from the skin where the incision will be made. For optimal effectiveness of the antiseptic, it is necessary to adhere to the time allotment for application before the surgical procedure, as outlined in manufacturer’s instructions. 5.1

What is decolonization for patient skin antisepsis?

Decolonization to decrease the bacterial load, specifically of S aureus, on the patient's body and in the nares is a part of a multimodal approach for preventing SSIs. 1.1

Convene an interdisciplinary team (i.e., one or more infection preventionists, epidemiologists, pharmacists, perioperative RNs, surgeons, microbiology laboratory personnel, and other stakeholders identified by the healthcare organization) to determine the need for and how to implement a preoperative methicillin-resistant Staphylococcus aureus [MRSA] and methicillin-sensitive S aureus [MSSA] decolonization program.

A successful decolonization program requires clear communication of your strategies, including required resources, defined responsibilities, end-user buy-in, and administrative support. 1.4

Why should patients bathe before surgery?

High-quality evidence indicates that patients who bathe with soap or an antiseptic before surgery may reduce the microbial flora on their skin before a surgical or other invasive procedure.

The benefits of preoperative patient bathing outweigh potential harms. Benefits include reduction of transient and resident microorganisms on the skin that may lower the patient’s risk of developing an SSI.2 The harms of preoperative patient bathing with an antiseptic may include skin irritation, allergic reaction, or unnecessary treatment with antiseptics. 2.1

Should hair be removed at the surgical site?

Leave hair at the surgical site in place unless hair removal is indicated. The benefits of leaving hair in place at the surgical site include preventing potential skin trauma from hair removal, potentially reducing the risk for SSI, and greater patient satisfaction. 3.1

How should you select the surgical site antiseptic?

Decisions about which preoperative skin antiseptic to use in the practice setting are complex. A variety of products may be necessary to meet the needs of various patient populations. Input from an interdisciplinary team with diverse experience and knowledge of skin antiseptics is helpful during review of the current research, clinical guidelines, and information provided by the manufacturers of surgical antiseptic agents. 4.1

Select an alcohol-based skin antiseptic for surgical site preparation unless contraindicated.

Alcohol is bactericidal and effective for surgical skin preparation but does not have persistent activity when used alone. Combining an alcohol-based solution with another antiseptic, such as CHG or povidone-iodine, provides a rapid, persistent, and cumulative effect. Alcohol-based antiseptics are broad spectrum and act immediately to lower the microbial count on skin. 4.2

Select the antiseptic product based on the anatomical location of the surgical procedure. Skin microbiota is dependent on the body site location (i.e., moist, dry, sebaceous), with each site harboring a specific array of bacteria. Consequently, each body part may have different responses to the same skin antiseptic. 4.2

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Patient Skin Antisepsis Guideline References

1. Lefebvre A, Saliou P, Lucet JC et al. Preoperative hair removal and surgical site infections: network meta-analysis of randomized controlled trials.J Hosp Infect. 2015;91(2):100–108. [IA] [PubMed: 26320612]
2. Dumville JC, McFarlane E, Edwards P, Lipp A, Holmes A, Liu Z. Preoperative skin antiseptics for preventing surgical wound infections after clean surgery.Cochrane Database Syst Rev. 2015;4:CD003949. [IA]
3. Webster J, Osborne S. Preoperative bathing or showering with skin antiseptics to prevent surgical site infection.Cochrane Database Syst Rev. 2015;2:CD004985. [IA]
4. Global Guidelines on the Prevention of Surgical Site Infection. Geneva, Switzerland: World Health Organization; 2016. [IVB] [PubMed: 30689333]
5. Surgical Site Infections: Prevention and Treatment. London, UK: National Institute for Health and Care Excellence (NICE); 2019. [IVA]