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Guideline for Prevention of Surgical Site Infection, 1999

Alicia J. Mangram, MD; Teresa C. Horan, MPH, CIC; Michele L. Pearson, MD; Leah Christine Silver, BS; William R. Jarvis, MD; The Hospital Infection Control Practices Advisory Committee

Hospital Infections Program
National Center for Infectious Diseases
Centers for Disease Control and Prevention
Public Health Service
US Department of Health and Human

Hospital Infection Control Practices Advisory Committee Membership List, January 1999

Chairman Executive Secretary

Elaine L. Larson, RN, PhD, FAAN, CIC
Michele L. Pearson, MD
Columbia University School of Nursing
New York, New York
Centers for Disease Control and Prevention
Atlanta, Georgia

Surgical Site Infection Guideline Sponsor

James T. Lee, MD, PhD, FACS
University of Minnesota
Minneapolis, Minnesota


Audrey B. Adams, RN, MPH
Montefiore Medical Center
Bronx, New York

Raymond Y. W. Chinn, MD
Sharp Memorial Hospital
San Diego, California

Alfred DeMaria, Jr, MD
Massachusetts Department of Public Health
Jamaica Plain, Massachusetts

Susan W. Forlenza, MD
New York City Health Department
New York, New York

Ramon E. Moncada, MD
Coronado Physician’s Medical Center
Coronado, California

William E. Scheckler, MD
University of Wisconsin Medical School
Madison, Wisconsin

Jane D. Siegel, MD
University of Texas Southwestern
Medical Center
Dallas, Texas

Marjorie A. Underwood, RN, BSN, CIC
Mt. Diablo Medical Center
Concord, California

Robert A. Weinstein, MD
Cook County Hospital
Chicago, Illinois


Executive Summary

The "Guideline for Prevention of Surgical Site Infection, 1999" presents the Centers for Disease Control and Prevention (CDC)’s recommendations for the prevention of surgical site infections (SSIs), formerly called surgical wound infections. This two-part guideline updates and replaces previous guidelines.[1,2]

Part I, "Surgical Site Infection: An Overview," describes the epidemiology, definitions, microbiology, pathogenesis, and surveillance of SSIs. Included is a detailed discussion of the pre-, intra-, and postoperative issues relevant to SSI genesis.

Part II, "Recommendations for Prevention of Surgical Site Infection," represents the consensus of the Hospital Infection Control Practices Advisory Committee (HICPAC) regarding strategies for the prevention of SSIs.[3] Whenever possible, the recommendations in Part II are based on data from well-designed scientific studies. However, there are a limited number of studies that clearly validate risk factors and prevention measures for SSI. By necessity, available studies have often been conducted in narrowly defined patient populations or for specific kinds of operations, making generalization of their findings to all specialties and types of operations potentially problematic. This is especially true regarding the implementation of SSI prevention measures. Finally, some of the infection control practices routinely used by surgical teams cannot be rigorously studied for ethical or logistical reasons (e.g., wearing vs not wearing gloves). Thus, some of the recommendations in Part II are based on a strong theoretical rationale and suggestive evidence in the absence of confirmatory scientific knowledge.

It has been estimated that approximately 75% of all operations in the United States will be performed in "ambulatory," "same-day," or "outpatient" operating rooms by the turn of the century.[4] In recommending various SSI prevention methods, this document makes no distinction between surgical care delivered in such settings and that provided in conventional inpatient operating rooms. This document is primarily intended for use by surgeons, operating room nurses, postoperative inpatient and clinic nurses, infection control professionals, anesthesiologists, healthcare epidemiologists, and other personnel directly responsible for the prevention of nosocomial infections.

This document does not:

  • Specifically address issues unique to burns, trauma, transplant procedures, or transmission of bloodborne pathogens from healthcare worker to patient, nor does it specifically address details of SSI prevention in pediatric surgical practice. It has been recently shown in a multicenter study of pediatric surgical patients that characteristics related to the operations are more important than those related to the physiologic status of the patients.[5] In general, all SSI prevention measures effective in adult surgical care are indicated in pediatric surgical care.
  • Specifically address procedures performed outside of the operating room (e.g., endoscopic procedures), nor does it provide guidance for infection prevention for invasive procedures such as cardiac catheterization or interventional radiology. Nonetheless, it is likely that many SSI prevention strategies also could be applied or adapted to reduce infectious complications associated with these procedures.
  • Specifically recommend SSI prevention methods unique to minimally invasive operations (i.e., laparoscopic surgery). Available SSI surveillance data indicate that laparoscopic operations generally have a lower or comparable SSI risk when contrasted to open operations.[6-11] SSI prevention measures applicable in open operations (e.g., open cholecystectomy) are indicated for their laparoscopic counterparts (e.g., laparoscopic cholecystectomy).
  • Recommend specific antiseptic agents for patient preoperative skin preparations or for healthcare worker hand/forearm antisepsis. Hospitals should choose from products recommended for these activities in the latest Food and Drug Administration (FDA) monograph.[12]

From the Hospital Infections Program, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Public Health Service, US Department of Health and Human Services, Atlanta, Georgia.
The Hospital Infection Control Practices Committee thanks the following subject-matter experts for reviewing a preliminary draft of this guideline: Carol Applegeet, RN, MSN, CNOR, CNAA, FAAN; Ona Baker, RN, MSHA; Philip Barie, MD, FACS; Arnold Berry, MD; Col. Nancy Bjerke, BSN, MPH, CIC; John Bohnen, MD, FRCSC, FACS; Robert Condon, MS, MD, FACS; E. Patchen Dellinger, MD, FACS; Terrie Lee, RN, MS, MPH, CIC; Judith Mathias, RN; Anne Matlow, MD, MS, FRCPC; C. Glen Mayhall, MD; Rita McCormick, RN, CIC; Ronald Nichols, MD, FACS; Barbara Pankratz, RN; William Rutala, PhD, MPH, CIC; Julie Wagner, RN; Samuel Wilson, MD, FACS. The opinions of all the reviewers might not be reflected in all the recommendations contained in this document.
The authors thank Connie Alfred, Estella Cormier, Karen Friend, Charlene Gibson, and Geraldine Jones for providing invaluable assistance.
Dr. Mangram is currently affiliated with the University of Texas Medical Center, Houston, Texas. Published simultaneously in Infection Control and Hospital Epidemiology, the American Journal of Infection Control, and the Journal of Surgical Outcomes.
This document is not copyright-protected and may be photocopied.
Address reprint requests to SSI Guideline, Hospital Infections Program, Mailstop E69, Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA 30333.
The "Guideline for Prevention of Surgical Site Infection, 1999 [PDF - 217 KB] " is available online. 99-SR-024. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR, the Hospital Infection Control Practices Advisory Committee. Guideline for the prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol 1999;20:[247-280].

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