Antimicrobial stewardship pathway

Closed surgical incisions

Assess risk

Assess patient and procedure complication risk factors (see below)^1–12

Initiate pre- and intra-operative SSI prevention measures per local protocol^9–11

0–1 risk factors → low risk

2 risk factors → medium risk

≥3 risk factors → high risk

Prophylactic antibiotics if indicated¹⁰⁻¹³

Risk factors for SSIs⁵⁻¹³

Patient risk factors

Advanced age
Chronic liver or kidney disease
Diabetes
Immunosuppression (drug induced or genetic)
Malnutrition
Obesity

Pre-operative nasal colonisation with Staphylococcus aureus
Respiratory conditions
Smoker/nicotine use
Steroid use
Drug/alcohol abuse/addiction

Prevent

Dress wound immediately after closure to minimise microbial burden and infection risk¹⁴⁻²²

Change dressings as required prior to wound progress check-up, per instructions for use

Standard dressings or microbial-binding dressings¹⁵⁻²¹* in low-risk patients

Microbial-binding dressings¹⁵⁻²¹* in medium-risk patients

Microbial-binding dressings¹⁵⁻²¹* and antibiotics per local guidance in high-risk patients

Assess

Assess for infection according to CDC classification^{8, 10, 22, 23}

Are there one or more of the criteria below within 30 days of surgery (90 days with prosthetics/implants)?

Centres for Disease Control and Prevention (CDC) classification of surgical site infections (SSIs)¹¹⁹ ¹⁴

Superficial incisional SSI:

Involves only skin and subcutaneous tissue of the incision

Deep incisional SSI:

Involves deep soft tissues of the incision (for example, fascial and muscle layers

Organ/spacel SSI:

Involves the organ/space tissues (deeper than the fascia/muscle

Superficial SSI

Involving only skin and subcutaneous tissue of the incision

Positive culture
Increased pain and tenderness
Localised swelling and induration
Localised heat and redness of the incision
Purulent drainage
Cellulitis not beyond 2 cm of incision margin
Evident superficial wound abscess
Superficial dehiscence
No evidence of deep or organ/space SSI

Deep SSI

Involving deep soft tissue

Positive culture
Increased pain, erythema and heat
Spreading induration and swelling
Purulent drainage
Cellulitis spreading ≥2 cm beyond margin
Evident deep abscess or fasciitis
Deep dehiscence
Postoperative fever
Raised blood CRP, WBC, ESR or PCT
No evidence of organ/space SSI

Organ/space SSI

Involving anatomy other than the incision

Positive culture
Purulent drainage from a drain placed through skin into the organ or body space
Organ or body-space abscess diagnosed by radiology or histopathology
Evidence of infection involving organ or body space observed during surgery
Postoperative fever
Raised blood CRP, WBC, ESR or PCT

Consider signs of sepsis²⁴

Signs of sepsis²⁴

Sepsis is a life-threatening condition in which the body's response to infection causes injury to its tissues and organs. Organ dysfunction is a key component in any diagnosis of sepsis.

Act on any of the following red flags:

S. Slurred speech or confusion

E. Extreme shivering or muscle pain

P. Passing no urine (in a day)

S. Severe breathlessness

I. It feels like you are going to die

S. Skin mottled or discoloured

Treat

Treat SSI and/or surgical wound dehiscence, including appropriate dressings^{15-21, 25-28}

Including wound bed preparation (therapeutic cleansing, debridement and repeat cleansing)^{22, 28}

Control microbial burden in surgical wound dehiscence without infection

First-line: Microbial-binding dressings¹⁵⁻²¹*

Treat superficial SSI

Referral: Surgical referral
First-line: Microbial-binding dressings¹⁵⁻²¹*
Second-line: Antiseptic dressings²⁸

Treat deep or organ/space SSI

Referral: Urgent surgical referral
Culture: Swab or tissue/fluid sample²³
Antibiotics: Targeted systemic antibiotics used with dressings^{26, 28}
First-line: Microbial-binding dressings¹⁵⁻²¹*
Second-line: Antiseptic dressings²⁸

Review

Notes

*Microbial-binding dressings have a DACC coating that can control microbial burden to prevent or manage infection in a way that is not expected to contribute to antimicrobial resistance. All treatments should be used per local policy and where clinically appropriate. This pathway applies to closed surgical incisions healing by primary intention. See below for supplementary tables, abbreviations and references.

Abbreviations

CDC=Centers for Disease Control and Prevention; CRP=C-reactive protein; DACC=dialkylcarbamoyl chloride ESR=erythrocyte sedimentation rates; PCT=pro-calcitonin; SSI=surgical site Infection; TIME=Tissue, Infection/inflammation, Moisture balance, Edge/epithelialisation; WBC=white blood cell.

Risk factors for SSIs⁵⁻¹³

Patient risk factors

Advanced age
Chronic liver or kidney disease
Diabetes
Immunosuppression (drug induced or genetic)
Malnutrition
Obesity
Pre-operative nasal colonisation with Staphylococcus aureus
Respiratory conditions
Smoker/nicotine use
Steroid use
Drug/alcohol abuse/addiction

Surgical procedure risk factors

Anatomical location of surgery (consult guidance for specifics)
Classification of surgery as clean, clean/contaminated, contaminated or dirty
Complexity of surgical procedure
Emergency procedure
Interruption of asepsis during surgery
Introduction of a prosthetic implant
Prolonged duration of surgery

Signs of sepsis²⁴

Sepsis is a life-threatening condition in which the body's response to infection causes injury to its tissues and organs. Organ dysfunction is a key component in any diagnosis of sepsis.

Act on any of the following red flags:

S. Slurred speech or confusion

E. Extreme shivering or muscle pain

P. Passing no urine (in a day)

S. Severe breathlessness

I. It feels like you are going to die

S. Skin mottled or discoloured

Guidance

Centers for Disease Control and Prevention (2025)

Surgical site infection

International Surgical Wound Complications Advisory Panel (2025)

Guideline for post-operative incision care

International Wound Infection Institute (2022)

Wound infection in clinical practice

World Health Organization (2018)

Global guidelines for the prevention of surgical site infection

World Union of Wound Healing Societies (2018)

Surgical wound dehiscence: improving prevention and outcomes

DACC™-coated dressings instructions for use

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click for REFERENCES

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