**Background:** Surgical site infections (SSIs) are common complications in acute-care facilities, occurring in approximately 1%–3% of patients undergoing inpatient surgery, depending on the operative procedure. In 2021, 21,186 SSIs were reported to the CDC National Healthcare Safety Network (NHSN) from 2,759,027 operative procedures. SSIs are among the most common and costly healthcare-associated infections (HAIs), with up to 60% considered preventable using evidence-based guidelines. Patients with SSI have a 2–11 times higher risk of death compared to operative patients without SSI, and 77% of deaths in patients with SSI are directly attributable to the infection. Attributable costs vary but are estimated to account for $3.5 billion to $10 billion annually in US healthcare expenditures. This document updates the 2014 SHEA Compendium, incorporating literature through August 2021, and categorizes recommendations as essential practices (for all hospitals) or additional approaches (for specific settings when SSIs persist).
**Methods:** SHEA recruited three subject-matter experts to lead a panel representing SHEA, IDSA, APIC, AHA, The Joint Commission, and CDC. A medical librarian developed a comprehensive search strategy for PubMed and Embase (January 2012–July 2019, updated to August 2021). Abstracts were reviewed by at least two panel members using Covidence, and selected abstracts were reviewed as full text. Recommendations were classified based on quality of evidence and balance between desirable and undesirable effects. The panel met via video conference to discuss findings and finalize recommendations. The draft was reviewed by the Compendium Expert Panel, partner organizations, and CDC, and approved by the SHEA Guidelines Committee, IDSA Practice Standards and Guidelines Committee, AHA, and The Joint Commission.
**Key Results:** The document presents essential practices for all acute-care hospitals, including: (1) Administer antimicrobial prophylaxis according to evidence-based standards, with discontinuation at the time of surgical closure in the operating room. For cefazolin, use 2 grams for patients ≤120 kg and 3 grams for patients >120 kg. (2) Use a combination of parenteral and oral antimicrobial prophylaxis prior to elective colorectal surgery (quality of evidence: HIGH). A 2019 meta-analysis of 40 studies found this combination significantly reduces SSI, postoperative ileus, anastomotic leak, and 30-day mortality. (3) Decolonize surgical patients with an antistaphylococcal agent for orthopedic and cardiothoracic procedures (quality of evidence: HIGH). A randomized, double-blind, placebo-controlled, multicenter trial showed decolonization with intranasal mupirocin and chlorhexidine bathing was associated with a >2-fold reduction in risk for postoperative S. aureus infection and an almost five-fold reduction in deep-incisional SSI due to S. aureus. (4) Use antiseptic-containing preoperative vaginal preparation for cesarean delivery or hysterectomy (quality of evidence: MODERATE). Use of povidone-iodine or chlorhexidine-based vaginal preparation reduces endometritis by 59%. (5) Use alcohol-containing preoperative skin preparatory agents in combination with an antiseptic (quality of evidence: HIGH). Four RCTs comparing chlorhexidine-alcohol to povidone-iodine-alcohol showed favorable results for chlorhexidine-alcohol; for example, Tuuli et al. (1,147 cesarean deliveries) found a 45% reduction in SSI (relative risk, 0.55; 95% CI, 0.34–0.90; P = .02). (6) Maintain normothermia (>35.5°C) during the perioperative period (quality of evidence: HIGH). (7) Use impervious plastic wound protectors for gastrointestinal and biliary tract surgery (quality of evidence: HIGH). A meta-analysis of 14 RCTs in 2,689 patients reported a 30% decrease in SSI risk. (8) Perform intraoperative antiseptic wound lavage with sterile dilute povidone-iodine (quality of evidence: MODERATE). A 2017 meta-analysis of 21 RCTs found an odds ratio of 0.31 (95% CI, 0.13–0.73) compared to nonantiseptic lavage. (9) Control blood-glucose level during the immediate postoperative period for all patients, maintaining levels between 110 and 150 mg/dL (quality of evidence: HIGH). (10) Use a checklist and/or bundle to ensure compliance with best practices (quality of evidence: HIGH). (11) Perform surveillance for SSI (quality of evidence: MODERATE). (12) Provide ongoing SSI rate feedback to surgical and perioperative personnel (quality of evidence: MODERATE). Additional approaches include negative-pressure dressings (moderate evidence for reduction in SSI, particularly in abdominal surgery and joint arthroplasty) and antiseptic-impregnated sutures (moderate evidence, with mixed results). Approaches not recommended include routine vancomycin prophylaxis (due to increased acute kidney injury risk and no difference in SSI rates compared to β-lactams), routine delay of surgery for parenteral nutrition, and routine use of antiseptic drapes.
**Clinical Implications:** This updated guidance provides a comprehensive, evidence-based framework for SSI prevention in acute-care hospitals. Key changes from 2014 include elevating decolonization for cardiothoracic and orthopedic procedures to an essential practice, lowering the postoperative blood glucose target to 110–150 mg/dL, and emphasizing discontinuation of antimicrobial prophylaxis at wound closure. The document highlights that up to 60% of SSIs are preventable and that implementation of these strategies can significantly reduce patient morbidity, mortality, and healthcare costs. Hospitals should prioritize essential practices and consider additional approaches when SSI rates remain elevated. The guidance also emphasizes the importance of surveillance, feedback, and a multidisciplinary approach to implementation.