HAI Prevention - Surgical Site Infections

Surgical Site Infection (SSI) Prevention

Resources and Data

Healthcare-associated infections (HAIs) - Surgical site infections (SSIs)

SSIs are infections that occur after surgery, in the area of the body where the procedure took place. SSIs are currently the most frequently reported serious HAIs among Wisconsin hospitals. Many hospitals and quality improvement organizations are working together to reduce these infections. The Division of Public Health provides frequently updated SSI data to monitor statewide progress toward SSI reduction.

Data and Statistics

Wisconsin SSI Data - Quarter 3, 2015
Number of hospitals reporting = 101

Data accessed from the National Healthcare Safety Network (NHSN) on February 11, 2016.

Infections following all reported procedures Total procedures performed

Wisconsin standardized infection ratio (SIR)






(Number of observed infections divided by the number of predicted infections based on national data.)

* Statistically significantly lower than the national baseline, but not significantly different from last year at this time.

Prevention resources

2015 SSI Summit - Presentations

Journal references - Last updated: January 19, 2016

Antimicrobial Prophylaxis - Weight-based Dosing

  • Bratzler D, Dellinger E, Olsen K, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm 2013;70:195-283
  • Catanzano A, Phillips M, Dubrovskaya Y, et al.The standard one gram dose of vancomycin is not adequate prophylaxis for MRSA. Iowa Orthop J. 2014;34:111-7.
  • Edmiston CE, Krepel C, Kelly H, et al. Peri-operative antimicrobial prophylaxis in the gastric bypass patient: Do we achieve therapeutic levels? Surgery 2004;136:738-747.
  • Hafermann MJ, Kiser TH, Lyda C, et al. Weight-based versus set dosing of vancomycin for coronary artery bypass grafting or aortic valve surgery. J Thorac Cardiovasc Surg. 2014 Jun;147(6):1925-30. doi: 10.1016/j.jtcvs.2013.12.037. Epub 2014 Jan 15.
  • Pevzner L, Swank M, Krepel C, et al. Effect of maternal obesity on tissue concentration of prophylactic cefazolin during cesarean section. Obstet Gynecol 2011;117:877-882.
  • Swank ML, Wing DA, Nicolau DP, et al. Increased 3-gram cefazolin dosing for cesarean delivery prophylaxis in obese women. Am J Obstet Gynecol. 2015 Sep;213:415.e1-8. doi: 10.1016/j.ajog.2015.05.030. Epub 2015 May 21.

Antimicrobial Wound Closure

  • Apisarnthanarak A, Singh N, Bandong AN, et al. Triclosan-coated sutures reduce the risk of surgical site infections: A systematic review and meta-analysis. Infect Control Hosp Epidemiol. 2015;36:169-79. doi: 10.1017/ice.2014.22.
  • Daoud FC, Edmiston CE, Leaper D. Meta-analysis of prevention of surgical site infections following incision closure with triclosan-coated sutures: Robustness to new evidence. Surgical Infect 2014;15(3):165-181.
  • Edmiston CE, Daoud FC, Leaper D. Is there an evidence-based argument for embracing an antimicrobial (triclosan)-coated suture technology to reduce the risk for surgical-site infections? A meta-analysis. Surgery 2013;154:89-100.
  • Edmiston CE, Krepel CJ, Marks RM, et al. Microbiology of explanted suture segments from infected and noninfected surgical patients. J Clin Microbiol 2013;51:417.
  • Edmiston CE, Seabrook GR, Cambria RA, et al. Molecular epidemiology of microbial contamination in the operating room environment: Is there a risk for infection? Surgery 2005;138:573-582.
  • Edmiston CE, Seabrook GR, Goheen MP, et al. Bacterial adherence to surgical sutures: Can antibacterial-coated sutures reduce the risk of microbial contamination? J Am Coll Surg 2006;203:481-489.
  • Kathju S, Nistico L, Hall-Stoodley L, et al. Chronic surgical site infection due to suture-associated polymicrobial biofilm. Surgical Infect 2009;10:457-461.
  • Singh A, Bartsch SM, Muder RR, Lee BY. An economic model: Value of antimicrobial-coated sutures to society, hospitals, and third-party payers in preventing abdominal surgical site infections. Infect Control Hosp Epidemiol 2014;35:1013-1020.

CHG Shower

  • Alawadi ZM, Kao LS. Chlorhexidine gluconate, 4%, showers and surgical site infection reduction. JAMA Surg 2015;E1.
  • Darouiche RO, Wall MJ, Itani KM. Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med 2010;362:18-26.
  • Denton GW. Chlorhexidine. In: Block SS, editor. Disinfection, Sterilization, and Preservation. 4th Ed. Media, PA: Lea & Febiger, Williams & Wilkins; 1991. p. 279.
  • Edmiston CE, Assadian O, Spencer M, et al. To bathe or not to bathe with chlorhexidine gluconate: Is it time to take a stand for preadmission bathing and cleansing? AORN J 2015;101:529-538
  • Edmiston CE, Bruden B, Rucinski MC, et al. Reducing the risk of surgical site infections: Does chlorhexidine gluconate provide a risk reduction benefit? Am J Infect Control. 2013;41(5 Suppl):S49-55.
  • Edmiston CE, Cheong JL, Krepel CJ, et al. Evidence for a standardized preadmission showering regimen to achieve maximal antiseptic skin surface concentrations of chlorhexidine gluconate, 4%, in surgical patients. JAMA Surg 2015;E1-E7.
  • Edmiston CE, Krepel CJ, Edmiston SE, et al. The preoperative shower revisited: Can high topical antiseptic levels be achieved on the skin surface prior to surgical admission? J Am Coll Surg 2008;207:233-239.
  • Edmiston CE, Krepel CJ, Edmiston SE, et al. Reducing the risk of surgical site infections: Does chlorhexidine gluconate provide a risk reduction benefit? Am J Infect Control 2013;41:S49-S55.
  • Edmiston CE, Krepel CJ, Edmiston SE, et al. Empowering the surgical patient: A randomized, prospective analysis of an innovative strategy for improving patient compliance to the preadmission showering protocol. In Press: J Am Coll Surg, 2014;219(2):256-64.
  • Edmiston CE, Krepel CJ, Spencer MP, et al. Preadmission application of 2% chlorhexidine gluconate (CHG): Enhancing patient compliance while maximizing skin surface concentrations. Infect Control Hosp Epidemiol. 2015 Dec 28:1-6. [Epub ahead of print].
  • Edmiston CE, Okoli O, Graham MB, et al. Improving surgical outcomes: An evidence-based argument for embracing a chlorhexidine gluconate (CHG) pre-operative shower (cleansing) strategy for elective surgical procedures. AORN J 2010;92:509-518.
  • Edmiston CE, Seabrook GR, Johnson CJ, et al. Comparison of a new and innovative 2% chlorhexidine impregnated cloth with 4% chlorhexidine as topical antiseptic for preparation of the skin prior to surgery. Am J Infect Control 2007;35:89-96.
  • Eiselt D. Presurgical skin preparation with a novel 2% chlorhexidine gluconate cloth reduces rates of surgical site infection in orthopaedic surgical patients. Orthopedic Nurs 2009;28:141-145.
  • Jakobsson J, Perlkvist A, Wann-Hansson C. Searching for evidence regarding using preoperative disinfection showers to prevent surgical site infections: A systematic review. Worldviews Evid Based Nurs. 2011;8(3):143-52.
  • Larson E. Guideline for use of topical antimicrobial agents. Am J Infect Control 1988;16(6):253-265.
  • Lipke VL, Hyott AS. Reducing surgical site infections by bundling multiple risk reduction strategies and active surveillance. AORN J 2010;92:288-296.
  • Mangram AJ, Horan TC, Pearson ML, et al. Guidelines for the prevention of surgical site infections. Infect Control Hosp Epidemiol 1999;27:97-134.
  • Paulson D. Efficacy evaluation of a 4% chlorhexidine gluconate as a full-body shower wash. Am J Infect Control 1993;21:205-209.

CHG Wound Irrigation

  • Barnes S, Spencer M, Graham D, Johnson HB. Surgical wound irrigation: A call for evidence-based standardization of practice. Am J Infect Control 2014;42:525-529.
  • Edmiston CE, Krepel CJ, Edmiston SE, et al. Reducing the risk of surgical site infections: Does chlorhexidine gluconate provide a risk reduction benefit? Am J Infect Control 2013;41:S49-S55.
  • Genuit T, Bochicchio G, Napolitano LM, et al. Prophylactic chlorhexidine oral rinse decreases ventilator-associated pneumonia in surgical ICU patients. Surg Infect 2001;2:5.
  • Lim KS, Kam PCA. Chlorhexidine – pharmacology and clinical applications. Anaest Intensive Care 2008;36(4):502-512.
  • McDonnell G, Russell AD. Antiseptics and disinfectants: Activity, action, and resistance. Clin Microbiol Rev 1999;12:147.

Colon Surgery Bundle


  • Bull A, Wilson J, Worth LJ, et al. A bundle of care to reduce colorectal surgical infections: An Australian experience. J Hosp Infect. 2011;78:297-301.
  • Keenan JE, Speicher PJ, Thacker JK, et al. The preventive surgical site infection bundle in colorectal surgery: An effective approach to surgical site infection reduction and health care cost savings. JAMA Surg 2014;149:1045-52.
  • Kiran RP, Murray AC, Chiuzan C, et al. Combined preoperative mechanical bowel preparation with oral antibiotics significantly reduces surgical site infection, anastomotic leak, and ileus after colorectal surgery. Ann Surg. 2015 Sep;262(3):416-25; discussion 423-5. doi: 10.1097/SLA.0000000000001416.
  • Shaffer VO, Baptiste CD, Liu Y, et al. Improving quality of surgical care and outcomes: Factors impacting surgical site infection after colorectal resection. Am Surg. 201;80:759-63.
  • Tanner J, Padley W, Assadian O, et al. Do surgical care bundles reduce the risk of surgical site infections in patients undergoing colorectal surgery? A systematic review and cohort meta-analysis of 8,515 patients. Surgery. 2015;158:66-77.
  • Walts S, Fritze D, Banerjee M, et al. Developing an argument for bundled interventions to reduce surgical site infection in colorectal surgery. Surgery 2014;4:602-06.

Guideline Evaluation

HAI Prevalence Data

Magill SS, Edwards JR, Bamberg W, et al. Multistate point prevalence survey of healthcare-associated infections. N Engl J Med 2014;370:1198-1208.

Infection Control Practices for Ambulatory Surgery Centers

MRSA Surveillance/Decolonization

  • Baratz MD, Hallmark R, Odum SM, et al. Twenty percent of patients may remain colonized with methicillin-resistant Staphylococcus aureus despite a decolonization protocol in patients undergoing elective total joint arthroplasty. Clin Orthop Relat Res. 2015;473:2283-2290.
  • Bebko SP, Green DM, Awad SS. Effect of a preoperative decontamination protocol on surgical site infections in patients undergoing elective orthopedic surgery with hardware implantation. JAMA Surg 2015;150(5):390-395.
  • Chen AF, Heyl AE, Xu PZ, et al. Preoperative decolonization effective at reducing staphylococcal colonization in total joint arthroplasty patients. J Arthroplasty. 2013;28(8 Suppl):18-20.
  • Chen AF, Wessel CB, Rao N. Staphylococcus aureus screening and decolonization in orthopaedic surgery and reduction of surgical site infections. Clin Orthop Relat Res. 2013;471:2383-2399.
  • Edmiston CE, Leaper DJ, Kiernan M. The ying and yang of pre-operative screening or methicillin-sensitive Staphylococcus aureus (MSSA): Would the extra effort and cost of decolonization reduce surgical site infections? Wound Medicine 2013;http://dx.doi.org/10.1016/j.wndm.2013.05.003.
  • Jarvis WR, Jarvis AA, Chinn RY. National prevalence of methicillin-resistant Staphylococcus aureus in inpatients at United States health care facilities, 2010. Am J Infect Control 2012;40:194-200.
  • Kawamura H1, Matsumoto K, Shigemi A, et al. A bundle that includes active surveillance, contact precaution for carriers, and cefazolin-based antimicrobial prophylaxis prevents methicillin-resistant Staphylococcus aureus infections in clean orthopedic surgery. Am J Infect Control. 2015 Oct 30. pii: S0196-6553(15)00987-6. doi: 10.1016/j.ajic.2015.09.014. [Epub ahead of print].
  • Kim DH, Spencer M, Davidson SM, et al. Institutional prescreening for detection and eradication of methicillin-resistant Staphylococcus aureus in patients undergoing elective orthopedic surgery. J Bone Joint Surg Am 2010;92:1820-1826.
  • Noorani HZ, Adams E, Glick S, et al. Screening for methicillin-resistant Staphylococcus aureus (MRSA): Future research needs: Identification of future research needs from comparative effectiveness review no. 102 [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2013 Jun.
  • O'Reilly EB, Johnson MD, Rohrich RJ. Comprehensive review of methicillin-resistant Staphylococcus aureus: Screening and preventive recommendations for plastic surgeons and other surgical health care providers. Plast Reconstr Surg. 2014;134:1078-89. doi: 10.1097/ PRS.0000000000000626.
  • Rao N, Cannella BA, Crossett LS, et al. Preoperative screening/decolonization for Staphylococcus aureus to prevent orthopedic surgical site infection: Prospective cohort study with 2-year follow-up. J Arthroplasty. 2011;26(8):1501-7.
  • Thakkar V, Ghobrial GM, Maulucci CM, et al. Nasal MRSA colonization: Impact on surgical site infection following spine surgery. Clin Neurol Neurosurg. 2014; 125:94-97.

Postoperative Wound Care

  • Leaper DJ. An overview of the evidence on the efficacy of silver dressings. The silver debate: A new consensus on what constitutes credible and attainable evidence. J Wound Care. March supplement 2011; 8-14.
  • Dobbelaere A, Schuermans N, Smet S, et al. Comparative study of innovative postoperative wound dressings after total knee arthroplasty. Acta Orthop Belg. 2015;81:454-61.
  • Hsieh PY, Chen KY, Chen HY, et al. Postoperative showering for clean and clean-contaminated wounds: A prospective, randomized, controlled trial. Ann Surg. 2015 Dec 10. [Epub ahead of print]
  • Kadar A, Eisenberg G, Yahav E, et al. Surgical site infection in elderly patients with hip fractures, silver-coated versus regular dressings: A randomised prospective trial. J Wound Care. 2015 Oct;24:441-2, 444-5. doi: 10.12968/jowc.2015.24.10.441.
  • Kummerow Broman K, Oyefule OO, Phillips SE, et al. Postoperative care using a secure online patient portal: Changing the (inter)face of general surgery. J Am Coll Surg. 2015 Dec;221(6):1057-66. doi: 10.1016 /j.jamcollsurg.2015.08.429. Epub 2015 Sep 23.
  • Pellino G. Preventing surgical site events: Any role for negative pressure wound therapy? J Am Coll Surg. 2014 Nov;219(5):1098. doi: 10.1016/ j.jamcollsurg.2014.07.015.Epub 2014 Oct 17.
  • Scalise A, Calamita R, Tartaglione C, et al.Improving wound healing and preventing surgical site complications of closed surgical incisions: A possible role of incisional negative pressure wound therapy. A systematic review of the literature. Wound J. 2015 Oct 1. doi: 10.1111/iwj.12492. [Epub ahead of print].
  • Toon CD, Lusuku C, Ramamoorthy R, et al. Early versus delayed dressing removal after primary closure of clean and clean-contaminated surgical wounds. Cochrane Database Syst Rev. 2015 Sep 3;9:CD010259. doi: 10.1002/14651858.CD010259.pub3.

Selective Interventional Strategies beyond SCIP

  • Bejko J, Tarzia V, Carrozzini M, et al. Comparison of efficacy and cost of iodine impregnated drape vs. standard drape in cardiac surgery: Study in 5100 Patients. J Cardiovasc Transl Res. 2015 Oct;8:431-7. doi: 10.1007/s12265-015-9653-1. Epub 2015 Sep 15.
  • Calfee DP. Considering universal mupirocin decolonization as an option for preventing surgical site infections. Clin Infect Dis. 2015 Dec 9. pii: civ992. [Epub ahead of print].
  • Daoud F, Edmiston CE, Leaper D. Meta-analysis: Prevention of surgical site infections following wound closure with triclosan-coated sutures: Robustness of new evidence. In Press: Surgical Infect 2014;15:165-181.
  • Edmiston CE, Daoud FC, Leaper D. Is there an evidence-based argument for embracing an antimicrobial (triclosan) suture technology for reducing the risk of surgical site infections (SSIs)?: A meta-analysis. Surgery 2013;154:89-100.
  • Edmiston CE, Spencer M, Lewis BD, et al. Reducing the risk of surgical site infections: Did we really think that SCIP would lead us to the promised land? Surgical Infect 2011;12:169-177.
  • Edmiston CE, Spencer M. Patient care interventions to help reduce the risk of surgical site infections. AORN 2014;100:590-602.
  • Fischer JE, Weintraub R. Two senior surgeons' view: prevention of surgical site infection associated with colorectal operations. Am J Surg. 2015;209:1107-10. doi: 10.1016/j.amjsurg.2014.10.024. Epub 2015 Jan 30.
  • Gheorghe A, Calvert M, Pinkney TD, et al. Systematic review of the clinical effectiveness of wound-edge protection devices in reducing surgical site infection in patients undergoing open abdominal surgery. West Midlands Research Collaborative; ROSSINI trial management group. Ann Surg 2012; 255: 1017-1029.
  • Gheorghe A, Roberts TE, Pinkney TD, et al. The cost-effectiveness of wound-edge protection devices compared to standard care in reducing surgical site infection after laparotomy: An economic evaluation alongside the ROSSINI trial and on behalf of the West Midlands Research Collaborative and the ROSSINI trial investigators. PLoS One 2014; 9: e95595 doi: 1371/journal.pone.0095595.
  • Gillespie BM, Kang E, Roberts S, et al. Reducing the risk of surgical site infection using a multidisciplinary approach: An integrative review. J Multidiscip Healthc. 2015 Oct 13;8:473-87. doi: 10.2147/ JMDH.S73565. eCollection 2015.
  • Hawn MT, Vick CC, Richman J, et al. Surgical site infection prevention: Time to move beyond the surgical care improvement program. Ann Surg 2011;254:494-501.
  • McKibben RA, Pitts SI, Suarez-Cuervo C, et al. Practices to reduce surgical site infections among women undergoing cesarean section: A review. Infect Control Hosp Epidemiol. 2015 May 20:1-7, [Epub ahead of print].
  • Ousey K, Edward KL, Stephenson J, et al. Cochrane Protocol. Perioperative warming therapy for preventing surgical site infection in adults undergoing surgery. Cochrane Library Issue 6, 2015.
  • Spruce L. Back to basics: Surgical skin antisepsis. AORN J. 2016;103:95-103.
  • Wang ZX, Jiang CP, Cao Y, et al. Systematic review and meta-analysis of triclosan-coated sutures for the prevention of surgical site infection. Br J Surg 2013;100:465-73.

Risk Factors for Surgical Site Infections

  • Adhikary SD, Liu WM, Memtsoudis SG, et al. Body mass index more than 45 kg/m2 as a cutoff point is associated with dramatically increased postoperative complications in total knee arthroplasty and total hip arthroplasty. J Arthroplasty. 2015 Nov 10. pii: S0883-5403(15)00981-X. doi: 10.1016/j.arth.2015.10.042. [Epub ahead of print].
  • Chung CU, Wink JD, Nelson JA, et al. Surgical site infections after free flap breast reconstruction: An analysis of 2,899 patients from the ACS-NSQIP datasets. J Reconstr Microsurg. 2015;31(6):434-41. doi: 10.1055/s-0035-1548739. Epub 2015 Apr 24.
  • Cheng K, Li J, Kong Q, et al. Risk factors for surgical site infection in a teaching hospital: A prospective study of 1,138 patients. Patient Prefer Adherence. 2015 Aug 14;9:1171-7. doi: 10.2147/PPA.S86153. eCollection 2015.
  • Daley BJ, Cecil W, Clarke PC, et al. How slow is too slow? Correlation of operative time to complications: An analysis from the Tennessee Surgical Quality Collaborative. J Am Coll Surg. 2015;220(4):550-8. doi: 10.1016/j.jamcollsurg.2014.12.040. Epub 2015 Jan 9.
  • Esemuede IO, Murray AC, Lee-Kong SA, et al.  Obesity, regardless of comorbidity, influences outcomes after colorectal surgery-time to rethink the pay-for-performance metrics? J Gastrointest Surg 2014;18:2163-8.
  • Fei Q, Li J, Lin J, et al. Risk factors for surgical site infection following spinal surgery: A meta-analysis. World Neurosurg. 2015 Jun 5. pii: S1878-8750(15)00656-7. doi: 10.1016/j.wneu.2015.05.059. [Epub ahead of print].
  • Fu RH, Weinstein AL, Chang MM, et al. Risk factors of infected sternal wounds versus sterile wound dehiscence. J Surg Res. 2016 Jan;200:400-7. doi: 10.1016/j.jss.2015.07.045. Epub 2015 Aug 7.
  • Kohut AY, Liu JJ, Stein DE, et al. Patient-specific risk factors are predictive for postoperative adverse events in colorectal surgery: An American College of Surgeons National Surgical Quality Improvement Program-based analysis. Am J Surg. 2015;209:219-29. doi: 10.1016/j.amjsurg.2014.08.020. Epub 2014 Oct 13.
  • Maeda K, Kanaoka Y, Ohki T, et al. Better clinical practice could overcome patient-related risk factors of vascular surgical site infections. J Endovasc Ther. 2015 Jun 19. pii: 1526602815591553. [Epub ahead of print].
  • McKibben RA, Pitts SI, Suarez-Cuervo C, et al. Practices to reduce surgical site infections among women undergoing cesarean section: A review. Infect Control Hosp Epidemiol. 2015;20:1-7. [Epub ahead of print].
  • Olsen MA, Nickel KB, Wallace AE, et al. Stratification of surgical site infection by operative factors and comparison of infection rates after hernia repair. Infect Control Hosp Epidemiol 2015;36:329-35.
  • Pugely AJ, Martin CT, Gao Y, et al. The incidence of and risk factors for 30-day surgical site infections following primary and revision total joint arthroplasty. J Arthroplasty. 2015 Jun 3. pii: S0883-5403(15)00476-3. doi: 10.1016/j.arth.2015.01.063. [Epub ahead of print].
  • Shaffer VO, Baptiste CD, Liu Y, et al. Improving quality of surgical care and outcomes: Factors impacting surgical site infection after colorectal resection. Am Surg 2014;80:759-63.
  • Wiseman JT, Fernandes-Taylor S, Barnes ML, et al. Predictors of surgical site infection after hospital discharge in patients undergoing major vascular surgery. J Vasc Surg. 2015 Oct;62(4):1023-1031.e5. doi: 10.1016/j.jvs.2015.04.453. Epub 2015 Jul 3.

Surgical Care (General) Bundles

  • Alijanipour P, Heller S, Parvizi J. Prevention of periprosthetic joint infection: What are the effective strategies? J Knee Surg. 2014;27:251-8.
  • Le C, Guppy KH, Axelrod YV, Hawk MW, Silverthorn J, Inacio MC, Akins PT. Lower complication rates for cranioplasty with peri-operative bundle. Clin Neurol Neurosurg. 2014 May;120:41-4, doi: 10.1016/j.clineuro.2014.02.009. Epub 2014 Feb 25
  • Leaper DJ, Tanner J, Kieman M, Assadian O, Edmiston CE Jr. Surgical site infection: Poor compliance with guidelines and care bundles. Int Wound J. 2015;12:357-62.
  • Miyahara K, Matsuura A, Takemura H, et al. Implementation of bundled interventions greatly decreases deep sternal wound infection following cardiovascular surgery. J Thorac Cardiovasc Surg. 2014;148:2381-8.


Gwen Borlaug, Infection Control Epidemiologist
Wisconsin Division of Public Health 
Bureau of Communicable Diseases
Phone 608-267-7711
Fax 608-261-4976

Last Revised: April 22, 2016