Antimicrobial resistance
(and why), and set a review date to incorporate new evidence. Multidisciplinary agreement is essential: surgeons, anaesthetists, infection prevention, pharmacy and pre-assessment nursing should co-own the bundle.
Plan for Staphylococcus aureus across pathways, not just in high-risk pockets S. aureus remains a leading cause of SSIs across orthopaedic, cardiac, vascular and obstetric procedures. Professor Gee argued that services should proactively consider carriage in elective pathways where an SSI would carry significant morbidity. The operational question is not whether S. aureus matters, but how to address it efficiently. Options range from targeted screening with treatment of carriers to broader, procedure-specific approaches. The key is clarity: define which procedures trigger screening or decolonisation, who is responsible for initiating and documenting it and how exceptions are handled. Where deep prosthetic infection is catastrophic, tolerating ambiguity about S. aureus carriage is a risk decision as much as a clinical one.
Use nasal decolonisation and chlorhexidine body wash where indicated; reconcile national and local guidance Where S. aureus is relevant and the consequence of infection is high, most guidance supports a combination of nasal decolonisation and whole-body cleansing with chlorhexidine. Professor Gee noted that local policies
are increasingly signposting to national guidance, but differences remain and can create confusion. Services should explicitly reconcile any discrepancies: if local practice diverges, document the rationale and how risks are mitigated. Equally important is making the regimen executable by patients. Written instructions should be plain-English, stepwise and consistent across materials, such as letters, leaflets and text reminders. Consider literacy, translation and accessibility needs.
If using mupirocin, acknowledge resistance risk and design for adherence Mupirocin remains widely used for nasal decolonisation and can reduce SSI risk in
photo disinfection delivered on admission, offer appealing advantages: minutes to administer, single-episode compliance, and no contribution to antimicrobial resistance. Early data are promising when combined with standard whole-body cleansing. Such approaches may help where pre-op compliance is variable or admission-day standardisation is desirable, but services should expect high- quality comparative evidence before wholesale replacement of current standards. In the meantime, technology can be used within defined protocols, with outcome monitoring and governance oversight.
carriers when applied correctly. It is, however, an antibiotic with known resistance potential, and its effectiveness in practice depends on consistent completion of a multi-day pre-operative course. Professor Gee’s message was not to abandon mupirocin, but to deploy it thoughtfully. That means embedding stewardship safeguards – and avoiding unnecessary repeat courses – while ensuring prescriptions are generated without delay after screening results, and giving patients simple applicators with clear pictorial guidance. Where adherence proves challenging across the pathway, examine whether the regimen, the supply chain or the instructions are the friction points.
Choose between screening and universal approaches with eyes open to operational trade-offs Routine MRSA screening is standard; MSSA screening remains variable and adds workload: swabbing, lab processing, chasing results, communicating to patients, generating prescriptions, and re-checking adherence. Professor Gee suggested that, particularly when non-antibiotic intranasal options are in play, some units might examine a universal decolonisation approach for defined procedures. The calculus is a local one: screening targets treatment but creates failure points; universal approaches simplify operations but treat some patients who would not have needed it. The right answer may differ by procedure, population and capacity. What matters is recognising the trade-offs explicitly, modelling the pathway end- to-end, and measuring outcomes. These include SSI rates, cancellations, last-minute deferrals due to incomplete preparation and the patient experience. Whichever approach is chosen, make it stable, predictable and easy to execute.
A patient using nasal photodisinfection
Evaluate non-antibiotic intranasal technologies pragmatically and ethically Emerging technologies, such as intranasal
Embrace “marginal gains”: a suite of small, reliable improvements beats a single silver bullet Professor Gee described improvement programmes that tackled multiple peri- operative risks simultaneously, including optimising nutrition, preventing hypothermia, standardising skin antisepsis, refining theatre traffic, using tranexamic acid judiciously, and reducing transfusions where appropriate. None of these steps alone eliminates SSI, but together they shift the baseline. The “marginal gains” mindset helps teams avoid the trap of forever seeking the perfect intervention while neglecting the basics.
Make peri-operative hygiene executable: simple instructions, right products, right timing Seemingly mundane details often determine success. Professor Gee highlighted variability in the number and timing of pre-operative chlorhexidine washes. A practical, evidence- aligned position is to ensure multiple washes before surgery, with a particular emphasis on the morning-of-surgery cleanse. Services should standardise the message and the materials: provide patients with the correct volume of product, clear instructions (ideally with diagrams), and reminders aligned to their surgery date. Aligning communication across all touchpoints, such as clinic letters, text messages, pre-assessment conversations and theatre briefings, prevents contradictory advice.
Build data and feedback loops that clinicians actually use
Counting infections quarterly is too slow to guide practice. Professor Gee noted the need for near-real-time process measures (proportion of eligible patients completing nasal decolonisation; percentage receiving morning- of-surgery chlorhexidine wash) paired with outcome metrics. Crucially, this data should be presented in formats that teams can digest in minutes: a simple weekly run chart on the theatre
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