Surgical skin antisepsis

24 Feb 2014 | Infection Prevention & Control

Surgical skin antisepsis is one of the key interventions of the Health Quality & Safety Commission’s national Surgical Site Infection Improvement (SSII) Programme, led by Auckland and Canterbury district health boards (DHBs).

A surgical site infection (SSI) is an infection that develops as a result of a surgical procedure. SSIs are associated with increased morbidity and mortality, prolonged hospital stays and increased health care costs. The SSII Programme aims to reduce SSIs following hip and knee arthroplasty procedures and will focus on reducing SSIs following selected cardiac procedures over the next year.

Preoperative skin antisepsis is a simple and effective measure to reduce the risk of surgical site infections[1]. The primary source of organisms contributing to infection following surgery is the bacteria on a patient’s skin. The aim of skin antisepsis is to eliminate and rapidly kill skin flora at the site of a planned surgical incision[2].

Skin preparation of the operative site involves use of an antiseptic agent with both rapid and long-acting antimicrobial activity. Two types of preoperative skin preparation that combine alcohol (which has an immediate and dramatic effect on skin bacteria) with long-acting antimicrobial agents appear to be more effective at preventing SSI[3]. These are chlorhexidine gluconate plus alcohol (at least 70 percent) and povidone iodine plus alcohol (at least 70 percent).

An optimal surgical skin antisepsis preparation regimen that helps to reduce the risk of SSI ensures that patients receive an alcohol based antiseptic solution (at least 70 percent) containing either chlorhexidine gluconate or povidone iodine. Evidence supports the use of surgical skin antisepsis preparation for clean surgery involving the placement of a prosthesis or implant, clean-contaminated surgery and contaminated surgery[4].

While fires in the operating theatre are extremely rare, alcohol based antiseptics are flammable therefore the SSII programme recommends that careful precautions are taken when using alcohol based antiseptic skin preparation solutions. These include: staff education, ensuring that the liquid has completely dried by evaporation (three minutes is usually sufficient although longer may be required for areas where there is excess hair), and the use of low volume single use applicators to apply flammable antiseptic agents.

Allowing alcohol based skin antiseptics to dry completely before the start of the procedure is not only essential for safety but also effectiveness. Alcohol kills by evaporation where it denatures protein in bacterial cell walls, therefore wiping off wet skin preparation defeats the purpose of its use. Because of its flammability and the fact that alcohol achieves a substantial amount of kill as it dries, alcohol-based products should be allowed to air-dry completely before the procedure begins.

From October 2013 to March 2014, to complement the work being carried out by the SSII programme, the Open for better care campaign has promoted a bundle of interventions, with a particular focus on one each month:

  • November 2013: SSI surveillance
  • December 2013: Correct use of prophylactic antibiotics
  • January/February 2014: Using appropriate skin preparation before surgery
  • March 2014: Clipping not shaving the surgical site.



  1.  Maiwald, M. Chan, E.S.Y. The Forgotten Role of Alcohol: A Systematic Review and Meta-Analysis of the Clinical Efficacy and Perceived Role of Chlorhexidine in Skin Antisepsis, PLoS One 2012; 7(9): e44277
  2.  Safer Healthcare Now, Canada. 2011. Prevent Surgical Site Infections, Get Started Kit.
  3.  Institute for Healthcare Improvement (IHI). 2012. A How to guide: prevent surgical site infection for hip and knee arthroplasty
  4.  Surgical Site Infection Improvement Programme. 2014. Surgical Skin Antisepsis Preparation Intervention Guidelines.

Last updated 24/02/2014