Consensus Bundle on Prevention of Surgical Site Infections After Major Gynecologic Surgery

Published:December 07, 2016DOI:


      Surgical site infections are the most common complications of surgery in the United States. Of surgeries in women of reproductive age, hysterectomy is one of the most frequently performed, second only to cesarean birth. Therefore, prevention of surgical site infections in women undergoing gynecologic surgery is an ideal topic for a patient safety bundle. The primary purpose of this safety bundle is to provide recommendations that can be implemented into any surgical environment in an effort to reduce the incidence of surgical site infection. This bundle was developed by a multidisciplinary team convened by the Council on Patient Safety in Women's Health Care. The bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. In addition to recommendations for practice, each of the domains stresses communication and teamwork between all members of the surgical team. Although the bundle components are designed to be adaptable to work in a variety of clinical settings, standardization within institutions is encouraged.
      To read this article in full you will need to make a payment
      AWHONN Member Login
      AWHONN Members, full access to the journal is a member benefit. Use your society credentials to access all journal content and features

      Purchase one-time access:

      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Al-Niaimi A.N.
        • Ahmed M.
        • Burish N.
        • Chackmakchy S.A.
        • Seo S.
        • Rose S.
        • Connor J.
        Intensive postoperative glucose control reduces the surgical site infection rates in gynecologic oncology patients.
        Gynecologic Oncology. 2015; 136: 71-76
        • American College of Obstetricians and Gynecologists
        • Committee on Gynecologic Practice
        Solutions for surgical preparation of the vagina. Committee opinion no. 571.
        Obstetrics & Gynecology. 2013; 122: 718-720
        • American College of Obstetricians and Gynecologists
        • Committee on Gynecologic Practice
        Gynecologic surgery in the obese woman. Committee opinion no. 619.
        2015 (Retrieved from)
        • Association of periOperative Registered Nurses
        Perioperative standards and recommended practice for inpatient and ambulatory settings.
        Author, Denver, CO2015
        • Association of periOperative Registered NursesAORN Recommended Practices Committee
        Recommended practices for preoperative patient skin antisepsis.
        in: Perioperative standards and recommended practices. Author, Denver, CO2013: 75-90
        • Bazzi A.
        • Harris J.
        • Morgan D.
        • Pearlman M.D.
        • Reynolds R.
        • Campbell D.A.
        • Uppal S.
        Chlorhexidine-alcohol compared with povidone-iodine for surgical-site antisepsis after abdominal hysterectomy.
        American Journal of Obstetrics and Gynecology. 2016; 214: S463
        • Berenguer C.M.
        • Ochsner M.G.
        • Lord S.A.
        • Senkowski C.K.
        Improving surgical site infections: Using national surgical quality improvement program data to institute surgical care improvement project protocols in improving surgical outcomes.
        Journal of the American College of Surgeons. 2010; 210: 737-741
        • Bratzler D.W.
        • Dellinger P.
        • Olsen K.M.
        • Peri T.M.
        • Auwaerter P.G.
        • Bolon M.K.
        • Weinstein R.A.
        Clinical practice guidelines for antimicrobial prophylaxis in surgery.
        American Journal of Health-System Pharmacy. 2013; 70: 195-283
        • Bratzler D.W.
        • Houck P.M.
        Antimicrobial prophylaxis for surgery: An advisory statement for the National Surgical Infection Prevention Project.
        American Journal of Surgery. 2005; 189: 395-404
        • Bratzler D.W.
        • Houck P.M.
        • Richards C.
        • Steele L.
        • Dellinger E.P.
        • Fry D.E.
        • Red L.
        Use of antimicrobial prophylaxis for major surgery: Baseline results from the National Surgical Infection Prevention Project.
        Archives of Surgery. 2005; 140: 174-182
        • Brega A.G.
        • Barnard J.
        • Mabachi N.M.
        • Weiss B.D.
        • DeWalt D.A.
        • Brach C.
        • West D.R.
        AHRQ health literacy universal precautions toolkit (2nd ed.).
        2015 (Retrieved from)
        • Burke J.F.
        The effective period of preventive antibiotic action in experimental incisions and dermal lesions.
        Surgery. 1961; 50: 161-168
        • Centers for Disease Control and Prevention
        National diabetes statistics report: Estimates of diabetes and its burden in the United States, 2014.
        2014 (Retrieved from)
        • Centers for Disease Control and Prevention
        Healthcare-associated Infections.
        2016 (Retrieved from)
        • Correia M.I.
        • Waitzberg D.L.
        The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis.
        Clinical Nutrition. 2013; 22: 235-239
        • Cowperthwaite L.
        • Holm R.L.
        Guideline implementation: Preoperative patient skin antisepsis.
        AORN Journal. 2015; 101: 71-77
        • Culver D.H.
        • Horan T.C.
        • Gaynes R.P.
        • Martone W.J.
        • Jarvis W.R.
        • Emori T.G.
        • Hughes J.M.
        Surgical wound infection rates by wound class, operative procedure, and patient risk index. National Nosocomial Infections Surveillance System.
        American Journal of Medicine. 1991; 91: 152S-157S
        • Daniels L.
        Good nutrition for good surgery: Clinical and quality of life outcomes.
        Australian Prescriber. 2003; 26: 136-140
        • Dingley C.
        • Daugherty K.
        • Derieg M.K.
        • Persing R.
        Improving patient safety through provider communication strategy enhancements.
        in: Henriksen K. Battles J.B. Keyes M.A. Grady M.L. Advances in patient safety: New directions and alternative approaches. Vol. 3: Performance and tools (pp. 1–18). Agency for Healthcare Research and Quality, Rockville, MD2008
        • Garretson S.
        Benefits of pre-operative information programmes.
        Nursing Standard. 2004; 18: 33-37
        • Goldenhar L.M.
        • Brady P.W.
        • Sutcliffe K.M.
        • Muething S.E.
        Huddling for high reliability and situation awareness.
        BMJ Quality & Safety. 2013; 22: 899-906
        • Hawkins R.B.
        • Levy S.M.
        • Senter C.E.
        • Zhao J.Y.
        • Doody K.
        • Kao L.S.
        • Tsao K.
        Beyond surgical care improvement program compliance: Antibiotic prophylaxis implementation gaps.
        American Journal of Surgery. 2013; 4: 451-456
        • Hawn M.T.
        • Vick C.C.
        • Richman J.
        • Holman W.
        • Deierhoi R.J.
        • Graham L.A.
        • Itani K.M.
        Surgical site infection prevention: Time to move beyond the Surgical Care Improvement Program.
        Annals of Surgery. 2011; 254: 494-499
        • Haynes A.B.
        • Weiser T.G.
        • Berry W.R.
        • Lipsitz S.R.
        • Breizat A.S.
        • Dellinger P.
        A surgical safety checklist to reduce the morbidity and mortality in a global population.
        New England Journal of Medicine. 2009; 360: 491-499
        • Hedrick T.L.
        • Heckman J.A.
        • Smith R.L.
        • Sawyer R.G.
        • Friel C.M.
        • Foley E.F.
        Efficacy of protocol implementation on incidence of surgical site infection.
        Journal of the American College of Surgeons. 2007; 205: 432-438
      1. Institute for Healthcare Improvement. (n.d.). Huddles. Retrieved from

        • Kathiresan A.S.
        • Brookfield K.F.
        • Schuman S.I.
        • Lucci 3rd, J.A.
        Malnutrition as a predictor of poor postoperative outcomes in gynecologic cancer patients.
        Archives of Gynecology and Obstetrics. 2011; 284: 445-451
        • Kavanagh K.T.
        • Calderon L.E.
        • Saman D.M.
        • Abusalem S.K.
        The use of surveillance and preventative measures for methicillin-resistant staphylococcus aureus infections in surgical patients.
        Antimicrobial Resistance and Infection Control. 2014; 3: 18
        • Kelley M.
        • Weber D.J.
        • Dooley K.E.
        • Rutala W.A.
        Healthcare-associated methicillin-resistant Staphylococcus aureus.
        Seminars on Infection Control. 2001; 1: 157-171
        • Keshavarz H.
        • Hillis S.D.
        • Kieke B.A.
        • Marchbanks P.A.
        Hysterectomy surveillance—United States, 1994–1999.
        Morbidity and Mortality Weekly Report. 2002; 51 (Retrieved from): 1-8
        • Kirkland K.B.
        • Briggs J.P.
        • Trivette S.L.
        • Wilkinson W.E.
        • Sexton D.J.
        The impact of surgical-site infections in the 1990s: Attributable mortality, excess length of hospitalization, and extra costs.
        Infection Control and Hospital Epidemiology. 1999; 20: 725-730
        • Kjølhede P.
        • Halili S.
        • Löfgren M.
        Vaginal cleansing and postoperative infectious morbidity in vaginal hysterectomy. A register study from the Swedish National Register for Gynecological Surgery.
        Acta Obstetricia et Gynecologica Scandinavica. 2011; 90: 63-71
        • Kondrup J.
        • Allison S.P.
        • Elia M.
        • Vellas B.
        • Plauth M.
        ESPEN guidelines for nutrition screening 2002.
        Clinical Nutrition. 2003; 22: 415-421
        • Kurz A.
        • Sessler D.I.
        • Lenhardt R.
        Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group.
        New England Journal of Medicine. 1996; 334: 1209-1215
        • Lachiewicz M.P.
        • Moulton L.J.
        • Jaiyeoba O.
        Pelvic surgical site infections in gynecologic surgery.
        Infectious Diseases in Obstetrics and Gynecology. 2015; 2015: 614950
        • Leonard M.
        • Graham S.
        • Bonacum D.
        The human factor: The critical importance of effective teamwork and communication in providing safe care.
        Quality & Safety in Health Care. 2004; 13: i85-i90
        • Magill S.S.
        • Edwards J.R.
        • Bamberg W.
        • Beldavs Z.G.
        • Dumyati G.
        • Kainer M.A.
        • Fridkin S.K.
        Multistate point-prevalence survey of health care–associated infections.
        New England Journal of Medicine. 2014; 370: 1198-1208
        • Mangram A.J.
        • Horan T.C.
        • Pearson M.L.
        • Silver L.C.
        • Jarvis W.R.
        Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee.
        Infection Control & Hospital Epidemiology. 1999; 20: 250-278
        • Mauger B.
        • Marbella A.
        • Pines E.
        • Chopra R.
        • Black E.R.
        • Aronson N.
        Implementing quality improvement strategies to reduce healthcare-associated infections: A systematic review.
        American Journal of Infection Control. 2014; 42: S274-S283
        • McDonald M.
        • Gabsch E.
        • Marshall C.
        • Forbes A.
        Single- versus multiple-dose antimicrobial prophylaxis for major surgery.
        Australian and New Zealand Journal of Surgery. 1998; 68: 388-396
        • Merkow R.P.
        • Ju M.H.
        • Chung J.W.
        • Hall B.L.
        • Cohen M.E.
        • Williams M.V.
        • Bilimoria K.Y.
        Underlying reasons associated with hospital readmission following surgery in the United States.
        Journal of American Medical Association. 2015; 313: 483-495
        • MedlinePlus
        After surgery.
        2016 (Retrieved from)
        • Mu Y.
        • Edwards J.R.
        • Horan T.C.
        • Berrios-Torres S.I.
        • Fridkin S.K.
        Improving risk-adjusted measures of surgical site infection for the national healthcare safety network.
        Infection Control and Hospital Epidemiology. 2011; 32: 970-986
        • Nguyen N.
        • Yegiyants S.
        • Kaloostian C.
        • Abbas M.A.
        • Difronzo L.A.
        The Surgical Care Improvement Project (SCIP) initiative to reduce infection in elective colorectal surgery: Which performance measures affect outcome?.
        American Journal of Surgery. 2008; 74: 1012-1016
        • Pastor C.
        • Artinyan A.
        • Varma M.G.
        • Kim E.
        • Gibbs L.
        • Garcia-Aguilar J.
        An increase in compliance with the Surgical Care Improvement Project measures does not prevent surgical site infection in colorectal surgery.
        Diseases of the Colon & Rectum. 2010; 53: 24-30
        • Pear S.M.
        Patient risk factors and best practices for surgical site infection prevention.
        Managing Infection Control. 2007; (Retrieved from): 56-64
        • Perencevich E.N.
        • Sands K.E.
        • Cosgrove S.E.
        • Guadagnoli E.
        • Meara E.
        • Platt R.
        Health and economic impact of surgical site infections diagnosed after hospital discharge.
        Emerging Infectious Diseases. 2003; 9: 196-203
        • Pessaux P.
        • Msika S.
        • Atalla D.
        • Hay J.M.
        • Flamant Y.
        • French Association for Surgical Research
        Risk factors for postoperative infectious complications in noncolorectal abdominal surgery: A multivariate analysis based on a prospective multicenter study.
        Archives of Surgery. 2003; 138: 314-324
        • Qadan M.
        • Gardner S.A.
        • Vitale D.S.
        • Lominadze D.
        • Joshua I.G.
        • Polk Jr., H.C.
        Hypothermia and surgery: Immunological mechanisms and current practice.
        Annals of Surgery. 2009; 250: 134-140
        • Reichman D.E.
        • Greenberg J.A.
        Reducing surgical site infections: A review.
        Reviews in Obstetrics and Gynecology. 2009; 2: 212-221
        • Richards J.E.
        • Kauffmann R.M.
        • Obremskey W.T.
        • May A.K.
        Stress-induced hyperglycemia as a risk factor for surgical-site infection in non-diabetic orthopaedic trauma patients admitted to the intensive care unit.
        Journal of Orthopaedic Trauma. 2013; 27: 16-21
        • Rowley B.
        • Kerr M.
        • Van Poperin J.
        • Everett C.
        • Strommel M.
        • Lehto R.H.
        Perioperative warming in surgical patients: A comparison of interventions.
        Clinical Nursing Research. 2015; 24: 432-441
        • Savage M.W.
        • Pottinger J.M.
        • Chiang H.Y.
        • Yohnke K.R.
        • Bowdler N.C.
        • Herwaldt L.A.
        Surgical site infections and cellulitis after abdominal hysterectomy.
        American Journal of Obstetrics and Gynecology. 2013; 209: 108.e1-108.e10
        • Scott E.M.
        • Buckland R.
        A systematic review of the intraoperative warming to prevent postoperative complications.
        AORN Journal. 2006; 83: 1090-1113
        • Shah D.K.
        • Vitonis A.F.
        • Missmer S.A.
        Association of body mass index and morbidity after abdominal, vaginal, and laparoscopic hysterectomy.
        Obstetrics & Gynecology. 2015; 125: 589-598
        • So J.P.
        • Aleem I.S.
        • Tsang D.S.
        • Matlow A.G.
        • Wright J.G.
        Increasing compliance with an antibiotic prophylaxis guideline to prevent pediatric surgical site infection: Before and after study.
        Annals of Surgery. 2015; 262: 403-408
        • Sørensen L.T.
        Wound healing and infection in surgery. The clinical impact of smoking and smoking cessation: A systematic review and meta-analysis.
        Archives of Surgery. 2012; 147: 373-383
        • Sørensen L.T.
        • Karlsmark T.
        • Gottrup F.
        Abstinence from smoking reduces incisional wound infection: A randomized controlled trial.
        Annals of Surgery. 2003; 238: 1-5
        • Steinberg J.P.
        • Braun B.I.
        • Hellinger W.C.
        • Kusek L.
        • Bozikis M.R.
        • Bush A.J.
        • Kritchevsky S.B.
        Timing of antimicrobial prophylaxis and the risk of surgical site infections: Results from the trial to reduce antimicrobial prophylaxis errors.
        Annals of Surgery. 2009; 250: 10-16
        • Sullivan S.A.
        • Smith T.
        • Chauhan S.
        • Hulsey T.
        • Vandorsten J.P.
        • Soper D.
        Administration of cefazolin prior to skin incision is superior to cefazolin at cord clamping in preventing postcesarean infectious morbidity: A randomized controlled trial.
        American Journal of Obstetrics and Gynecology. 2007; 196: 455.e1-455.e5
        • The Joint Commission
        The Joint Commission's implementation guide for NPSG.07.05.01 on surgical site infections.
        2013 (Retrieved from)
        • The Joint Commission
        Most commonly reviewed sentinel event types.
        2016 (Retrieved from)
        • Uppal S.
        • Harris J.
        • Al-Niaimi A.
        • Swenson C.W.
        • Pearlman M.D.
        • Reynolds R.K.
        • Morgan D.M.
        Prophylactic antibiotic choice and risk of surgical site infection after hysterectomy.
        Obstetrics & Gynecology. 2016; 127: 321-329
        • Weiss B.D.
        Health literacy and patient safety: Help patients understand.
        2007 (Retrieved from)
        • Whiteman M.K.
        • Hillis S.D.
        • Jamieson D.J.
        • Morrow B.
        • Podgornik M.N.
        • Brett K.N.
        • Marchbanks P.A.
        Inpatient hysterectomy surveillance in the United States, 2000–2004.
        American Journal of Obstetrics and Gynecology. 2008; 198: 34.e1-34.e7
        • World Health Organization
        International statistical classification of diseases and related health problems (10th rev.).
        Author, Geneva, Switzerland2010
        • Wright J.T.
        • Herzog T.J.
        • Tsui J.
        • Ananth C.V.
        • Lewin S.N.
        • Lu Y.S.
        • Hershman D.L.
        Nationwide trends in the performance of inpatient hysterectomy in the United States.
        Obstetrics & Gynecology. 2013; 122: 233-241
        • Wu J.M.
        • Wechter M.E.
        • Geller E.J.
        • Nguyen T.V.
        • Visco A.G.
        Hysterectomy rates in the United States, 2003.
        Obstetrics & Gynecology. 2007; 110: 1091-1095
        • Zhang L.
        • Liu B.-C.
        • Zhang X.-Y.
        • Li L.
        • Xia X.-J.
        • Guo R.-Z.
        Prevention and treatment of surgical site infection in HIV-infected patients.
        BMC Infectious Diseases. 2012; 12: 115
        • Zinn J.
        • Jenkins J.B.
        • Swofford V.
        • Harrelson B.
        • McCarter B.
        Intraoperative patient skin prep agents: Is there a difference?.
        AORN Journal. 2010; 92: 662-671


      Joseph E. Pellegrini, PhD, CRNA, is an associate professor in the Department of Organizational Systems and Adult Health, University of Maryland School of Nursing, Baltimore, MD.


      Paloma Toledo, MD, MPH, is an assistant professor in the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL.


      David E. Soper, MD, is a professor in the Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC.


      William C. Bradford, DO, is the Vice President of Evaluation, American College of Osteopathic Obstetricians and Gynecologists, Fort Worth, TX.


      Deborah A. Cruz, MSN, RNC, CRNP, is a perinatal nurse practitioner and a clinical nurse specialist in the Department of Obstetrics and Gynecology, Thomas Jefferson University Hospital, Philadelphia, PA.


      Barbara S. Levy, MD, is the Vice President of Health Policy, American College of Obstetricians and Gynecologists, Washington, DC.


      Lauren A. Lemieux is a program manager, Strategic Health Care Initiatives, American College of Obstetricians and Gynecologists, Washington, DC.

      Linked Article