Risk factors

Patient: diabetes mellitus, obesity, smoking, malnutrition, immunosuppression, advanced age, prior MRSA colonisation, dermatitis at site.
Wound: contaminated, inflamed, on lower leg, periauricular, mucosal, large defect.
Operative: prolonged duration, tissue trauma, dead space, haematoma, foreign material.
Postoperative: poor dressing technique, premature wetting, mobilisation issues, infection at other sites.

Pre-operative measures

Hair management: avoid shaving; if hair removal needed, use clippers immediately before incision (NICE NG125).
Skin preparation: chlorhexidine gluconate 2% in 70% alcohol — first-line. Povidone-iodine alternative; aqueous chlorhexidine for periocular surgery (alcohol contraindicated near eyes).
Glucose control: aim HbA1c <8% pre-elective; intra-op glucose 6-10 mmol/L.
Smoking cessation: ≥4 weeks pre-elective surgery reduces flap / graft loss significantly.
MRSA decolonisation: nasal mupirocin 2% TDS × 5 days + chlorhexidine wash if known carrier or in high-prevalence settings.
Optimise pre-op nutrition; address active eczema / wound at site.
Do not stop standard antiplatelet / DOAC routinely (see anticoagulation monograph).

Sterile field: sterile drapes, gowns, gloves; surgical hand hygiene with chlorhexidine 4% or alcohol gel for ≥2 minutes (first case) / 90 seconds (subsequent cases).
Antibiotic prophylaxis: when indicated, single dose 30-60 min before incision (separate monograph).
Normothermia: maintain core temperature >36 °C with forced-air warming, warmed irrigation, ambient temperature.
Oxygenation: maintain SpO2 >95%; high FiO2 (80%) during anaesthesia for major cases.
Tissue handling: minimise tissue trauma; clear plane dissection; avoid excessive diathermy.
Haemostasis: meticulous; eliminate dead space; consider drainage for large flaps.
Glove change at completion of dirty parts; consider double-gloving for high-risk cases.
Closure: layered; absorbable subcutaneous to remove tension; appropriate suture selection (see suture monograph).

Sterile dressing for ≥48 h; advanced dressings (hydrocolloid, silicone, alginate) per wound.
Closed-incision NPWT (PICO): NICE HTG509 (formerly MTG43) supports prophylactic use over high-risk closed incisions — inguinal / axillary lymphadenectomy, sternotomy, abdominal closure under tension.
Mobilisation early; elevate operated limb.
Glycaemic and analgesia control.
Wound care: clear written instructions, when to wet, signs of infection.
Follow-up 7-14 days; sooner if high-risk closure.

Local SSI surveillance; benchmark against published rates (clean skin surgery 1-3%).
Root-cause analysis for cluster outbreaks (instrument cycle, single surgeon, MRSA breach).
Patient feedback and post-discharge surveillance — patients commonly present to GP with SSI; structured questionnaires capture true rate.
Multidisciplinary review at MDT for major reconstruction failures.