What the evidence says:

• We found no studies which assessed whether environmental disinfection had an effect on surgical site infections. However, we found some evidence showing that contamination of surfaces within the sterile field increased the incidence of infections. These surfaces could have become contaminated before or during the procedure and, therefore, we think it is important that blood and body fluids should be cleaned as soon as possible.
• We found no studies which assessed the effectiveness of different environmental disinfection agents.
• We found very weak evidence which suggested that adding automated disinfection devices (e.g. continuous environmental disinfection system or ultraviolet light devices) did not have any effect on surgical site infections.

What we recommend:

• All patient, staff and visitor hand and body contact surfaces must be cleaned between each patient.
• In addition to cleaning, all these surfaces need to be disinfected after dirty/contaminated procedures or after contamination with blood and body fluids.
• We think it’s good practice to clean and disinfect all clinical care equipment machines between all patients.
• We think it’s good practice to clean and disinfect anaesthetic room hand contact surfaces before the next patient arrives.

What the evidence says:

• We found no studies which assessed whether these areas have any impact on surgical site infections.

What we recommend:

• We made no recommendations, but we think that it is good practice to continue the current housekeeping routine.

What the evidence says:

• We found no studies which assessed whether clutter has any impact on surgical site infections. However, we think this may be a safety risk and may make cleaning routines less efficient.

What we recommend:

• We made no recommendations, but we think that it is good practice to keep the operating room tidy and devoid of clutter.

What the evidence says:

• We found no studies which assessed the effect of this contamination on the risk of developing blood-borne infections.

What we recommend:

• We made no recommendations, but we think that it is good practice to clean/disinfect floors and easily accessible areas contaminated by blood and body fluids splashes as soon as they occur.
• We do not think it is necessary to stop the use of the operating room to replace the ultraclean ventilation canopy screens or filters if they become contaminated. We think it is better to avoid delays and interruptions to the operating schedule.

What the evidence says:

• We found no studies which assessed whether allowing patients to be brought in a wheelchair or on a ward bed results in theatre contamination or increased risk of surgical site infections. We think that as long as these items (and bedding) are clean, they will have little effect.
• We found very weak evidence that using theatre trolley transfer systems (i.e. transferring patients to an operating theatre trolley) has no effect on theatre contamination or surgical infections. We found two studies which reported that the floors could be less contaminated when this system was used but one of these studies also reported that this had no influence on the contamination of the theatre air. We, therefore, do not think this system is necessary.

What we recommend:

• We made no recommendation, but we think there is no need for operating theatre trolley system and patients can walk in or be brought on clean beds, wheelchairs or trolleys.
• We think it is good practice to that linen is clean before it is brought to the operating theatre.

What the evidence says:

• We found very weak evidence which suggested that there was no difference in the incidence of post-operative infections when compared patients who were operated on after an infected case when compared to those operated after a non-infected case. We think that cleaning/disinfection is more important than the order of patients on the operating list. We also think that the order on the list is not always practical and that, sometimes, this can lead to unnecessary delays for a person who is placed last on a list and that this can potentially put some more vulnerable patients at risk.

What we recommend:

• We do not think that there is a need to place infected/colonised patients at the end of an operating list, but theatres can decide on their own. However, we do recommend that the operating room is cleaned and disinfected to standard between patients and that the theatres think about the practical aspects of the lists.

What the evidence says:

• We found no studies which investigated this topic. However, we think that if a patient was placed on contact precautions, these should be maintained in all parts of the hospital, including the operating theatre.

What we recommend:

• We think it is best practice to allow patients with isolation/contact precautions to recover separately from other patients, either in the operating room or in a designated section of the recovery area.

What the evidence says:

• We found no studies which assessed the effectiveness of non-disinfectant bath or shower. However, we found one study which reported that the infection rates were the same in hospitals which had the pre-operative shower initiative as a part of SSI prevention bundle when compared to the hospitals which did not. Thus, we do not think this practice is needed for infection control, but it can be encouraged for personal hygiene and the comfort of the patients.
• We found some evidence that chlorhexidine showers/baths had no effect on SSI when compared to plain soap, placebo or when patients were not required to shower or bathe. However, we found some evidence that chlorhexidine wipes may be beneficial. Therefore, we do not think that showers/baths are necessary but wipes (e.g. chlorhexidine) can be used in circumstances where patients were not able to shower or bathe before an operation.

What we recommend:

• We made no recommendations, but we think it is good practice to encourage patients to shower/bathe before surgery for personal hygiene reasons.
• We think that it is good practice to use alternatives (e.g. wipes) immediately before surgery for patients who were not able to shower or bathe beforehand.
• We think that it is best not to delay operations for patients who are not able to shower or bathe before the surgery.
• We think it is important to instruct patients not to shave their surgical area before the surgery. This was not assessed in out guidelines, but we are aware that this recommendation is underpinned by strong evidence against this practice.

What the evidence says:

• We think that the current NICE recommendations [NG125] provide adequate advice on this topic and should be followed by the operating theatre team.

What we recommend:

• We recommend that theatres refer to the NICE guidelines [NG125] for advice on this topic (recommendations 1.3.7, 1.3.8, 1.3.9 and accompanying Table 1).

What the evidence says:

• We found no studies which investigated the effect of the timing of laying-up the instruments on the incidence of surgical infections. However, we found some evidence which suggested that when the instruments were laid up and left uncovered, there were more likely to become contaminated. We think the longer the instruments are left uncovered, the more likely that the contamination will occur and that this can potentially lead to infections. We also think that the same principles apply to any other materials inserted into the surgical wounds, such as prostheses.

What we recommend:

• We recommend that for all surgical/operative procedures, the lay-up of the instruments and prosthetic materials is as close as possible to when they are needed.

What the evidence says:

• We found weak evidence that suggested that there was no difference in the incidence of surgical site infections when the instruments were laid up under the ultraclean canopy. However, we found some evidence that this practice results in instruments being less contaminated. Therefore, we think that, if it is possible, instruments should be laid up under the ultraclean ventilation canopy. We also think that the same principles apply to any other materials inserted into the surgical wounds, such as prostheses.

What we recommend:

• We did not make any recommendations, but we think it is good practice to lay up the instruments/prosthetic materials under the ultraclean ventilation canopy if this exists.

What the evidence says:

• We think that the current NICE recommendations [NG125] provide adequate advice on this topic and should be followed by the operating theatre team.

What we recommend:

• We recommend that theatres refer to the NICE guidelines [NG125] for advice on this topic (recommendations 1.3.1 and 1.3.2).

What the evidence says:

• We found weak evidence which suggested that the higher number of door openings (used as a proxy for staff movement) negatively affects the incidence of surgical infections and the theatre air contamination, although the effect was not very large. On the other hand, we found one study which suggested that the number of door openings did not influence the extent of wound contamination. We think that the door opening itself does not have much effect on infections, however we think that door opening should be minimised to prevent non-essential staff entering the theatre. We also think door openings are distracting to the team and potentially detrimental to the patients, especially if these distractions lead to a longer surgery. We also acknowledge an importance of the presence of students for the purpose of teaching and we consider their presence essential.

What we recommend:

• We recommend that non-essential staff movement (and hence door openings) are minimised.

What the evidence says:

• We found one study which reported that the incidence of surgical infection did not increase after one surgeon started wearing a wedding band. However, we also found one study which reported an outbreak of post-operative infections which were linked to one surgeon whose skin under rings (worn during the surgery) carried the same strain of the microorganism. We also found that the hands of the surgeons who wore rings or wedding bands were more contaminated and that the glove perforations occurred more often when these items were worn. We think that when jewellery is worn, this interferes with appropriate scrubbing and that, in some instances, this may result in hands being inappropriately scrubbed. Thus, we think that jewellery worn below the elbows should not be allowed or, in rare circumstances where rings cannot be removed, more attention is given to scrubbing.
• We found no studies which investigated the effect of artificial nails or nail polish on the incidence of surgical infections. However, we did find a study which reported that an outbreak was linked to a theatre technician wearing artificial nails. We also found evidence that the nails of the staff who wore nail polish were more contaminated than in staff who did not. Therefore, we think that artificial nails and nail polish should not be allowed.

What we recommend:

• We recommend that hospitals do not allow scrubbed staff to wear jewellery below the elbow. Alternatively, in some circumstances where jewellery cannot be removed, the area around and underneath any item of jewellery must be carefully cleaned as much as possible during the scrubbing process.
• We recommend that hospitals do not allow scrubbed and unscrubbed staff to wear artificial or polished nails in the operating theatre.

What the evidence says:

• We found no studies which investigated the effect of wearing a headgear on the risk of post-operative infections, however we found some very weak evidence which suggested that when headgear is not worn, this results in more theatre contamination. We also found some evidence which suggested that the type of the headgear (cap vs bouffant) is not important. Overall, we do not think that wearing headgear influences the risk of infections unless the staff member has a condition which makes the skin flaky. However we think that that headgear has always been a part of a standard surgical attire and, therefore, should be worn for practical reasons (e.g. when deciding who should wear them and when), maintaining discipline, and recognising who’s who in the operating theatre.

What we recommend:

• We made no recommendations, but we think it is best practice that staff working in the operating room wear a head covering. The individuals can be given a choice to wear the headgear they prefer.

What the evidence says:

• We found moderate evidence, but the results are inconsistent, and it is not possible to determine the overall effect of face masks on the incidence of surgical infections. However, we also found one study which reported an outbreak which occurred due to a surgeon only covering the mouth but leaving the nose exposed and one study which reported that the trial had to be terminated early because a large number of infections occurred in ‘no masks group’. We also found some evidence that not wearing masks resulted in more contamination of the operating room. Thus, even though the effectiveness of masks on the incidence of post-operative infections has not yet been established, we think that wearing them is good practice. Besides reinforcing discipline, they may protect staff from blood and body fluid splashes, and at certain times, they may be required for preventing transmission of other infections (e.g. as observed during the recent pandemic).

What we recommend:

• We made no recommendations, but we think it is best practice that staff working in the operating room wear face masks. The staff also need to ensure that these are changed periodically.

What the evidence says:

• We found no studies which investigated the effect of wearing a headgear on the risk of post-operative infections, however we found some very weak evidence which suggested that when headgear is not worn, this results in more theatre contamination. We also found some evidence which suggested that the type of the headgear (cap vs bouffant) is not important. Overall, we do not think that wearing headgear influences the risk of infections unless the staff member has a condition which makes the skin flaky. However we think that that headgear has always been a part of a standard surgical attire and, therefore, should be worn for practical reasons (e.g. when deciding who should wear them and when), maintaining discipline, and recognising who’s who in the operating theatre.

What we recommend:

• We made no recommendations, but we think it is best practice that staff working in the operating room wear a head covering. The individuals can be given a choice to wear the headgear they prefer.

What the evidence says:

• We found no studies which assessed whether wearing operating theatre attire outside the operating theatre influences the incidence of post-operative infections or results in contamination of the theatre. We found some evidence which suggests that if the staff change before leaving the operating theatre or cover up with a coat, their operating room attire is less contaminated. However, we also found evidence that many staff are not compliant with this practice and assessing the real effect is difficult. We think that in many situations, changing or covering up may not be necessary. However, there are certain parts of the hospital where the risk of contamination with significant microorganisms may be higher (e.g. ICU). Since it is not feasible to monitor where the staff go outside the theatre, it is also not possible to determine whether they entered high risk areas. For this reason, we think it is best practice that all staff either change or cover their attire if they plan to return to the operating theatre.

What we recommend:

• We made no recommendations, but we think it is best practice that staff change or cover their attire if they leave the operating theatre with the intention of returning.

What the evidence says:

• We found no evidence which investigated this topic. We think that, at the moment, we cannot make any recommendations about patient jewellery, nail polish and artificial nails. We do however acknowledge that these items may need to be removed for other reasons, e.g. oximetry or for preventing injury during electrocautery.

What we recommend:

• We made no recommendations, and we think that hospitals need to refer to their own policies. We also think it is good practice that hospitals inform the patients in advance when they ask the patients to remove these items.

What the evidence says:

• We found no evidence which investigated this topic. We are aware that some hospitals no longer follow this policy and there seems to be no increase in the rates of surgical infections as a result of this new practice. Thus, we do not think that patients need to cover their hair for infection prevention reasons.

What we recommend:

• We made no recommendations, but we think this practice is no longer necessary.

What the evidence says:

• We found no evidence which investigated this topic. We think that, at the moment, this practice may not be necessary because most parents and carers will only enter the anaesthetic room and, on occasions where a birthing partners accompany women who are undergoing caesarean procedures, are going to be outside the sterile field. Other visitors will enter an operating room only during the time when no surgery is taking place. However, to help maintaining the discipline and identifying essential people in the theatre, we think that all visitors need to wear the attire in line of the attire worn by staff. We think that PPE may not be necessary in most circumstances, but the requirement may change depending on a situation.

What we recommend:

• We made no recommendations, but we think it is good practice to ask all parents, carers and visitors to wear the same attire as the operating team. We also think that it is good practice to ensure that all visitors are compliant with the local policy.

Authors:

Hilary Humphreys (chair)              Healthcare Infection Society/ ESCMID Study Group for Nosocomial Infections

Elisabeth Ridgway                           Healthcare Infection Society

Peter Wilson                                     Healthcare Infection Society

Margreet Vos                                   European Society of Clinical Microbiology and Infectious Diseases/

                                                            ESCMID Study Group for Nosocomial Infections

Kate Woodhead

Claire Haill

Deborah Xuereb                              European Society of Clinical Microbiology and Infectious Diseases

Joanna Walker                                 Healthcare Infection Society, Trainee Committee representative

Jennifer Bostock                              Lay representative

Thomas Pinkney

Rashmi Kumar                                  Lay representative

Peter N Hoffman                             Healthcare Infection Society

Thank you to other contributors:

Dr Markus Klimek, Dr Seven Johannes Aghdassi, Ms Lynn Skelton.