Surgical Site Preparation

Why surgical site preparation plays a key role in SSI prevention

Illustration of surgery tools
The KRINKO explains:

Preoperative antisepsis of the surgical field plays a key role in the prevention
of SSI, because when the integument (skin, mucous membranes, eye) is cut,
the resident flora should be prevented from being carried into the depths of
the surgical field.1

For the WHO the “surgical site preparation" refers to the preoperative
treatment of the intact skin of the patient within the OR”2, but in our
illustrations sterile covering is also taken into account.


GuidelineRecommendationCategory (if mentioned)
CDC3,4“Thoroughly wash and clean at and around the incision site to remove gross contamination before performing antiseptic skin preparation.”3

Category IB

“Perform intraoperative skin preparation with an alcohol based antiseptic agent unless contraindicated.”4

Category IA–strong recommendation; high quality evidence

“Apply preoperative antiseptic skin preparation in concentric circles moving toward the periphery. The prepared area must be large enough to extend the incisionor create new incisions or drain sites, if necessary.”3Category II
“Application of a microbial sealant immediately after intraoperative skin preparation is not necessary for the prevention of SSI.”4Category II–weak recommendation; low quality evidence
“The use of plastic adhesive drapes with or without antimicrobial properties is not necessary for the prevention of SSI.”4Category II–weak recommendation; high to moderate-quality evidence
”Use surgical gowns and drapes that are effective barriers when wet (i.e., materials that resist liquid penetration).”Category IB
WHO2“The panel recommends alcohol-based antiseptic solutions based on CHG for surgical site skin preparation in patients undergoing surgical procedures.”

Strong recommendation, low to moderate quality of evidence

“The panel suggests that antimicrobial sealants should not be used after surgical site skin preparation for the purpose of reducing SSI.”Conditional recommendation, very low quality of evidence
“The panel suggests that either sterile, disposable, non-woven or sterile, reusable woven drapes and surgical gowns can be used during surgical operations for the purpose of preventing SSI.”Conditional recommendation, moderate to very low quality of evidence
“The panel suggests not to use plastic adhesive incise drapes with or without antimicrobial properties for the purpose of preventing SSI.”Conditional recommendation, low to very low quality of evidence

“Do not use non-iodophor-impregnated incise drapes routinely for surgery as they may increase the risk of surgical site infection.”
“If an incise drape is required, use an iodophor-impregnated drape unless the patient has an iodine allergy.”
“Prepare the skin at the surgical site immediately before incision using an antiseptic preparation.”
“Be aware of the risks of using skin antiseptics in babies, in particular the risk of severe chemical injuries with the use of chlorhexidine (both alcohol-based and aqueous solutions) in preterm babies.”
“When deciding which antiseptic skin preparation to use, options may include those in table 1.” (Table 1 see below)

“If diathermy is to be carried out:

  • use evaporation to dry antiseptic skin preparations
  • avoid pooling of alcohol-based preparations.”
  • -

    The commission recommends, in the operating room, thorough antisepsis of the skin in the operating area should be carried out using an alcohol-based skin antiseptic. By adding a remanent antiseptic, a lasting effect beyond the effect of alcohol is achieved. Which active substance is to be preferred is currently unclear.

    Category IA

    For antiseptics on mucous membranes and the eye, use antiseptics approved for the respective area of application. Keep the skin area thoroughly wetted and moist during the declared exposure time, preferably by applying the antiseptic several times. Pay attention to the longer exposure time on skin areas rich in sebaceous glands. Care must also be taken to ensure that the patient does not lie in an accumulation of fluid from the skin antiseptic, as this can lead to skin necrosis and deflagration.

    Category IB,
    Category III,
    Category II,
    Category II

    After antisepsis of the surgical field, the area surrounding the surgical site must be sterilely draped. For operations where moisture penetration cannot be ruled out, use liquid-impermeable drapes. The use of non-antiseptic impregnated incision drapes is not recommended.
    Surgical ring drapes do not offer demonstrable advantages in terms of prevention of SSI in all operations.

    Category IB,
    Category IB,
    Category IB,
    Category I


    Denise Leistenschneider, Senior Clinical Consultant
    “The human skin plays a decisive role in the development of SSI and should therefore be given special attention in prevention.”

    What is recommended?

    Icon of an injury cover
    • Use (alcohol-based1–3) skin antiseptic (based onCHG2) to prepare the patient’s skin in the operating room1–5

    icon of arrow in circle
    • Apply the antiseptic in concentric circles from the centre to the periphery and take into account apossible widening of the incision and the insertion of a drain when determining the size of the prepared field.3

    icon of a drop
    • Avoid accumulation of alcohol-based fluid to prevent necrosis and deflagration.1,5

    icon of layers
    • Use drapes, if necessary.1,3

    • Do not use plastic adhesive drapes.2,4

    Icon of a question mark
    • There is no uniform recommendation as to whether and how (incise) drapes and should be impregnated.

    NICE: options for antiseptic skin preparation (table 1)5

    WhenChoice of antiseptic skin preparation
    First choice unless contraindicated or the surgical site is next to a mucous membraneAlcohol-based solution of chlorhexidine
    Alternative if the surgical site is next to amucous membraneAqueous solution of chlorhexidine
    Alternative if chlorhexidine is contraindicatedAlcohol-based solution of povidone-iodine
    If both an alcohol-based solution and chlorhexidine are unsuitableAqueous solution of povidone-iodine

    Short view in history6

    Icon of 50% postoperative mortality
    Before the middle of the 19th century, amputation was still associated with a post-operative mortality rate of 50% due to sepsis. The English surgeon Joseph Lister linked the spread of microorganisms through surgical wounds to deaths in the post-operative phase and began treating wounds with carbolic acid (phenol). The incidence of surgical sepsis fell dramatically and modern antiseptic techniques were introduced.
    MIP advice
    All content and recommendations listed are to be regarded as extracts from the original literature and do not claim to be exhaustive.
    Click to see full list References
    1. KRINKO (2018) Prävention postoperativer Wundinfektionen. Empfehlungen der Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO) beim Robert Koch-Institut. Bundesgesundheitsbl 61: 448–473.
    2. WHO (2018) Global guidelines for the prevention of surgical site infection. World Health Organization 2018.
    3. CDC (1999) Guideline for Prevention of Surgical Site Infection. Infect Control Hosp Epidemiol. 20(4): 247–278.
    4. Berrios-Torres SI, et al. (2017) Centers of Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg152(8): 784–791.
    5. NICE (2020) Surgical site infections: prevention and treatment. NICE guidelines. Published: 11 April 2019. Last updated: 19 August
    6. Hemani ML, Lepor H (2009) Skin Preparation for the Prevention of Surgical Site Infection: Which Agent Is Best? Rev Urol 11(4): 190–195.

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