Preoperative Measures to Prevent Surgical Site Infections

We regret to report there has been an error in the April, 2001 issue of Infection Control Today®. In the Best Practices article entitled Preoperative Measures to Prevent Surgical Site Infections, by Carolyn A. Ramsey, we incorrectly labeled the answer for test question #8 as being true. The answer is actually false. We regret the error.

Preoperative Measures to Prevent Surgical Site Infections

By Carolyn A. Ramsey, RN, MSN, CNOR

Figure 1. Use of battery operated clippers. Performed in the preoperative holding area.

The fight against post-operative wound infections has long been undertaken by practitioners. We appreciate that surgical site infections (SSIs) are frequently caused by bacteria commonly found on the skin. Therefore, reducing the number of bacteria on the skin has been a common preoperative practice. Standards and recommended practices from the Association of periOperative Registered Nurses (AORN) state preoperative skin preparation of surgical patients should include little or no hair removal, cleansing of the area around the surgical site, and use of an antiseptic agent immediately before the surgical incision.1

Hair Removal

Removal of hair at the surgical incision site has been discussed for some time. Traditionally, the surgeon has always made the decision of how much hair should be removed and the technique for removal. Many studies show hair removal with a razor or clippers can cause skin abrasion, or even nicks in the skin, which can lead to the development of pseudofolliculitis and subsequent SSIs. In a study discussed in the Guideline for Prevention of Surgical Site Infection, 1999, "SSI rates were 5.6% in patients who had hair removed by razor shave compared to a 0.6% rate among those who had hair removed by depilatory or who had no hair removed."2 To have the best patient outcome, perioperative nurses should be involved with physician education in areas of preoperative preparation and infection control.

Plastic surgeons have requested hair be left in place on patients having scalp lacerations as early as 20 years ago. Neurosurgeons have notoriously shaved the entire head for all types of cranial surgery. An editorial in The Lancet described a non-controlled study that showed no increase in infection rate when scalp hair was left in place. The patients shampooed with chlorhexidine the night before surgery. In the OR the scalp was scrubbed for eight minutes and irrigated with alcohol. The hair was parted at the proposed incision site and tied back.3 Leaving hair intact greatly reduces the patients' anxiety, especially when it can be readily seen, as on the head.

Price lists skin preparation as a major intrusion into the patients' body space. Removal of hair also can be very embarrassing for the patient, giving them a sense of loss of control and even a loss in sexual identity, especially when pubic hair is removed. Discomfort is felt while the hair removal is taking place, and serves as a constant reminder of the surgical experience and illness while the hair is growing back.4 This discomfort and reminder could have an adverse effect on the psychological recovery of patients undergoing surgery.

In 1979, Tkach, Shannon, and Beastrom conducted a study of patients having lower abdominal surgery to compare close shaving of the pubic hair with a technique developed to leave approximately 1 mm of stubble. By leaving stubble, it was felt that the patient would be less likely to develop pseudofolliculitis. Course, kinky hair is especially susceptible to re-growing out of the side of the follicle and curling up into the skin, causing an ingrown hair.5

The best practice is to refrain from hair removal unless it interferes with the surgical procedure or wound closure.6 If hair is removed, it should be done so using clippers or a depilatory cream (Figure 1). Razors have no place in the preoperative setting. It has been reported that surgical residents or surgeons have used a razor to remove hair in an emergency situation to save time. In this situation, it would be better to leave hair intact.

Depilatory Creams

Figure 2. Use of a Povidone-Iodine scrub in the operating room.

Depilatory creams are usually used the night before surgery. Most patients having elective surgery are not hospitalized the night before surgery; therefore, careful instructions must be given to patients who are expected to use the depilatory cream before coming to the hospital or outpatient surgery center. A skin sensitivity test must be performed to assure no allergies are present. Depending on the surgical site, the process can be time consuming and tedious, but may save the patient embarrassment if carried out before he or she reports for surgery. The nursing staff must be reminded to leave any hair that might not have responded to the depilation, or remove using clippers, just before surgery in an area outside of the operating room.

In 1983, 253 patients took part in a study by de Koos and McComas. Half of the subjects had skin prepared for surgery using a wet shave 30 minutes before surgery. The other half used a depilatory cream the night before surgery. The results of this study showed no statistical difference in the infection rate between the two methods of hair removal. All of the subjects also were given a preoperative shower of povidone-iodine soap the night before surgery and on the day of surgery,7 which may account for the discrepancy in the findings, compared to similar studies.

Preoperative Showers

Preoperative showers have also been used to reduce skin colonization of staphylococci, a frequent organism found in post-operative wound infections. In a study conducted in 1988, chlorhexidine gluconate (Hibiclens) was found to be more effective in reducing organisms than povidone-iodine (Betadine).8 Other studies also showed Hibiclens to be the preferred agent of choice for preoperative showers. One study compared the results of preoperative baths and showers. Showers were found to reduce more skin bacteria than baths. The most effective number of showers was also studied. Bryne revealed a study that included eight showers. When showers were compared to hand disinfection, flora decreased up to the fifth time the hands were washed.9 Two showers were most frequently advised--one the night before surgery and one the morning of the procedure.

The agent used to cleanse the skin before surgery and the agent used in the operating room to disinfect the surgical site have also been discussed. Chlorhexidine is frequently used as a preoperative shower. It is well tolerated and does not leave discoloration as a povidone-iodine preparation does. Hayek (1989) described a study that compared 4% Chlorhexidine and an unnamed bar soap. Considering methods of showering that could not be controlled, and definitions of surgical infection, the study was inconclusive, but Hayek continued to recommend Chlorhexidine be used in preoperative cleansing.10 Chlorhexidine can also be used immediately before the surgical incision, but many practitioners are choosing a povidone-iodine and alcohol product(Figure 2). The one-step application saves time and leaves a film on the skin that continues to reduce the number of bacteria during the surgical procedure.

Recently, lay magazines and news reports have discussed the everyday use of antimicrobial soaps and lotions. Described as a concern by Byrne "suppression of the normal flora ... has led to colonization by Proteus species."11 We should perhaps limit antimicrobial soaps except in cleansing minor cuts and abrasions. Normal flora has a role in protecting the body against potential harmful pathogens.


In conclusion, preoperative skin preparation continues to be an area of varied procedures. Healthcare providers strive to provide surgical patients with a safe and non-complicated recovery. Prevention of infection is of utmost concern. Preoperative reduction of skin flora remains the goal and standard of care. Skin should be cleansed before surgery. Preoperative showers have been adopted as a routine in many hospitals. Patients are given a chlorhexidine soap to use the night before surgery and the morning of surgery. If the patient is hospitalized before surgery, the nursing staff assists the patient with a shower or bath as appropriate.

Hair should ideally be left in place. If hair interferes with the surgical procedure it can be removed using scissors or clippers, and should be carried out in an area outside the operating room. A patient's privacy must be of utmost concern and a professional atmosphere and uncluttered space should be provided. Many preoperative areas consist of a large room with only curtains separating patients, providing little in the way of privacy. If this is the case, staff should keep this in mind and speak quietly at all times. If possible, a separate room should be used for hair removal.

Additional cleansing is performed immediately before the surgical incision is made in the operating room using sterile technique. The nurse checks patient allergies and after the patient is anesthetized and positioned, a sterile prep is carried out. Basic principles include using an antimicrobial agent, preventing unnecessary exposure, beginning the prep at the incision site, and working outward toward the periphery. Once the sponge is used on the outer edges, it should be discarded and not used at the incision area again. If a combination povidone-iodine/ alcohol agent is used, the same principles are used. When using this product, one application is all that is necessary. A film of antimicrobial agent remains on the skin during the surgical procedure, which prolongs the bacterial kill. Practitioners should keep in mind that even the most rigid preoperative preparation cannot reduce the need for strict aseptic technique, gentle handling of tissues and control of bleeding to help prevent postoperative SSI's.


1. Association of Operating Room Nurses (AORN). Recommended Practices for Skin Preparation of Patients, In: Standards, Recommended Practices and Guidelines. Denver: AORN; 2000:329-333.
2. Mangram, A J, Horan, T C, Pearson M L, Silver, L C, and Jarvis, W R. Guideline for Prevention of Surgical Site Infection. Infection control and Hospital Epidemiology. 1999; 20(4):257-258.
3. Editorial, Shaving the Head: Reason or Ritual? Lancet. 1992; 340(8829): 1198-1199.
4. Price B, Dignity That Must Be Respected. Body Image and the Surgical Patient. Professional Nurse. 1993; 8(10): 670-672.
5. Tkach J R, Shannon A M, and Beastrom R Pseudofolliculitis Due to Preoperative Shaving. A.O.R.N. Journ. 1979; 30(5): 881-884.
6. McIntyre F J, and McCloy R, Shaving Patients Before Operation: A Dangerous Myth? Ann R Coll Surg Engl. 1994; 76(1): 3-4.
7. deKoos Paul T, and McComas Bruce Shaving Versus Skin Depilatory Cream for Preoperative Skin Preparation. American Journal of Surgery. 1983; 145(3): 377-378.
8. Kaiser A B, Kernodle D S, Barg N L, and Petracek M R Influence of Preoperative Showers on Staphylococcal Skin Colonization: A Comparative Trial of Antiseptic Skin Cleansers. Annals of Thoracic Surgery. 1988; 45(1): 35-38.
9. Byrne D J, Napier A, and Cuschieri A Rationalizing Whole Body Disinfection. Journal of Hospital Infection. 1990; 15(2): 183-187.
10. Hayek L A Placebo-controlled trial of the Effect of Two Preoperative Baths or Shower: With Chlorhexidine Detergent on Postoperative wound Infection Rates. Journal of Hospital Infection. 1989; 13(2): 202-204.
11. Byrne D J, Napier A, Phillips G, and Cuschieri A Effects of Whole Body Disinfection on Skin Flora in Patients Undergoing Elective Surgery. Journal of Hospital Infection. 1991; 17(3): 217-222.


To describe the AORN preoperative skin preparation recommendations. To describe the importance of hair and removal. To identify the importance of preoperative showers.

True or false questions

1. AORN recommends total hair removal during preoperative skin preparation.
2. Hair removal increases patient anxiety.
3. If hair is removed, it should be done with a razor.
4. Preoperative showers are used to reduce staphylococci.
5. Baths reduce more skin bacteria than showers.
6. Normal flora protects the body from harmful pathogens.
7. A patient's privacy should not be the top concern when handling preoperative hair removal.
8. A nurse should check for allergies after the patient is anesthetized.
9. Nurses should begin prepping at the incision and work outward.
10. Two applications of povidone-iodine solution should be used to prep the incision site.


1. F.
2. T.
3. F.
4. T.
5. F.
6. T.
7. F.
8. T.
9. T.
10. F.

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