PREVENTION & SURVEILLANCE

GUIDELINE

MEDICAL CARE QUALITY SECTION

MEDICAL DEVELOPMENT DIVISION
MINISTRY OF HEALTH MALAYSIA
 Surgical Site Infection Guideline
2023

This document was developed by the Clinical Audit Unit, Medical Care Quality Section of
Medical Development Division, Ministry of Health, Malaysia and the National Technical
Working Group of Surgical Site Infection.

Completed in December 2022

Published by Ministry of Health Malaysia in August 2023

Medical Development Division

Block E1 Complex E
Federal Government Administrative Centre
62590 Federal Territory of Putrajaya
Malaysia

A catalogue record of this document is available from the National Library of Malaysia

ISBN: 978-967-2469-62-9

A copy of this document is also available at MOH Portal:

https://hq.moh.gov.my/medicaldev/ckpp/unit-audit-klinikal/

Copyright © Ministry of Health Malaysia.

All rights reserved. No part of this publication may be reproduced or distributed in any form
or by any means or stored in a database or retrieval system without prior written
permission from the Ministry of Health Malaysia.

i
PREAMBLE

t is with utmost pleasure that I pen this Foreword for Malaysia’s 1st Surgical
Site Infection (SSI) Prevention and Surveillance Guideline which has been
formulated by a strong multidisciplinary team comprising of Surgeons from
various Surgical Specialties, Anaesthetists and Infectious Diseases Physicians
from various Ministries. I would like to thank and congratulate everyone involved in
producing this Guideline especially the Clinical Audit Unit of Ministry of Health, Malaysia
along with the members of the Technical Working Group (TWG). They have been charged
with many tasks which includes initiating and establishing a Malaysian policy to meet
global standards but ensure that they are still feasible for adaptation within our
healthcare facilities.

A countries growth is measured based on its healthcare delivery system. As we thrust

Malaysia from a low- to upper-middle-income country, our
healthcare delivery should be modernised constantly. This
guideline is now on par with The United Nations Sustainable
Development Goals (SDG) 2030, G4 Alliance
recommendations and the Medical Programme Strategic
Plan 2021-2025.

With the birth of this Guideline, this becomes a reference for

healthcare professionals to ensure protocols and procedures
are adhered to. When appropriately adapted and in place, we
can aim to prevent and reduce the risk. It is my devout hope
that everyone works hand in hand to comply with the
standard practices, to reduce any variations in practice.
This requires a high level of commitment from the
healthcare workers (HCWs) which is astutely integral in
providing the best quality of care. As Henri Frederic
Amiel, a Swiss poet aptly said, “In health there is
freedom. Health is the first of all liberties”. I sincerely
hope, we provide the freedom of health to all our
patients.

DATUK DR. MUHAMMAD RADZI BIN ABU HASSAN

DIRECTOR GENERAL OF HEALTH
MINISTRY OF HEALTH MALAYSIA
AUGUST 2023

ii
FOREWORD

he Medical Development Division (MDD) under the Medical Programme of the

MOH, plays a critical role in ensuring the effective planning and implementation
of healthcare policies and programs cinching the smooth sailing of all the
hospitals. With the country’s growing population, there is an increasing need to
ensure all healthcare workers are up to date in their knowledge and skills to
accommodate the growing demand for quality healthcare services. One such activity is
the development of the Surgical Site Infection Prevention Guideline and Surveillance.

Surgical site infection (SSI) can be a serious complication for patients undergoing surgical
procedures. Till date, in Malaysia, there are no specific guidelines in place to prevent and
manage SSI in healthcare facilities. In this guideline, we focus on the prevention of SSIs
before, during and after the surgery. A Surveillance is also in placed to identify patients
who may be at risk to develop an SSI and these cases will be discussed by the National
Surgical Site Infection Committee which was recently formed during the development of
this guideline. This guideline aims to educate all healthcare professionals in preventing
and managing SSI as well as to educate the patients on their role in
preventing SSI.

Overall, the committee has established a comprehensive

framework for preventing and managing SSI in healthcare
facilities. By adhering to these guidelines and implementing
effective infection control strategies, patients can receive optimal
care and minimize the risk of infections during surgical
procedures. SSI is a preventable complication, and
healthcare professionals have a responsibility to mitigate
this risk. By taking a proactive approach and adhering to
established infection control protocols, we can
significantly reduce the incidence of surgical site
infections, resulting in safer, effective and efficient
patient care.

A simple but effective quote that perfectly encapsulates

this notion is, "an ounce of prevention is worth a pound
of cure." With that, I hope this book will guide us, the
HCWs, in preventing and reduce the burden of SSI.

DATO' DR ASMAYANI BINTI KHALIB

DEPUTY DIRECTOR GENERAL OF HEALTH (MEDICAL)
MINISTRY OF HEALTH MALAYSIA
AUGUST 2023

iii
PREFACE
Surgical site infection (SSI) is an infection occurring after surgery which is undesirable and
has serious outcomes. Preventing SSI has become increasingly important in ensuring that
patients receive the best care possible. According to the World Health Organisation
(WHO), SSI is a leading Healthcare Associated Infection (HCAI); thus, we seized the
opportunity to produce this guideline which has unravelled the complexities involved in
SSI prevention.

As healthcare providers, we must stay abreast of the latest developments and

management in preventing SSI. By the implementation of this Guideline, we have
ventured into making this challenging task of SSI prevention simpler and more
straightforward to facilitate our fellow comrades in providing the best
care for our patients.

The Technical Working Group (TWG) was formed in 2020, however

we had to pause in 2021 due to the global pandemic of COVID-
19. However, we resumed in 2022 and had convened several
times since then to complete this Guideline. Despite facing
many hurdles and hiccups, we came to a consensus and
produced this Surgical Site Infection Prevention and
Surveillance Guideline. This book is aimed to equip every
healthcare worker with the knowledge of SSI Prevention.

In conclusion, managing SSI is key to providing the best

healthcare for our patients. I extend my sincere gratitude to
the members of the National TWG and the Clinical Audit Unit,
Ministry of Health for their time and effort in materialising this
Guideline. I hope we benefit from this Guideline and able to
implement it to our patient’s benefit.

DR SAADON BIN IBRAHIM

CHAIRMAN OF THE NATIONAL SSI COMMITTEE
MINISTRY OF HEALTH MALAYSIA
AUGUST 2023

iv
 ACKNOWLEDGEMENT
TAN SRI DATO’ SERI DR NOOR HISHAM ABDULLAH

MEMBERS OF THE TECHNICAL WORKING GROUP (TWG)

MINISTRY OF HEALTH MALAYSIA

GENERAL SURGERY

Dr Yap Lee Ming

Senior Consultant General Surgeon

ORTHOPAEDIC SURGERY

Dr Saadon Bin Ibrahim

Senior Consultant Orthopaedic Surgeon

Dr Mohamad Fauzlie bin Yusof

Senior Consultant Orthopaedic Surgeon

Dr Zairuddin bin Abdullah Zawawi

Senior Consultant Orthopaedic Surgeon

OBSTETRICS & GYNAECOLOGY

Dr Marinah binti Ab. Wahab

Senior Consultant Obstetrician & Gynaecologist

Dr Mohammad Faiz bin Mohamad Jamli

Senior Consultant Obstetrician & Gynaecologist

CARDIOTHORACIC SURGERY

Dr Ahmadi bin Salleh

Senior Consultant Cardiothoracic Surgeon

BREAST & ENDOCRINE SURGERY

Dr Sadhana binti Sadar Mahamad

Senior Consultant Breast & Endocrine Surgeon

v
 VASCULAR SURGERY

Dr Hafizan bin Mohd Tajri

Senior Consultant Vascular Surgeon

PAEDIATRIC SURGERY

Dr Mohd Tarmizi bin Md Nor

Senior Consultant Paediatric Surgeon

Dr Tammy Teoh Han Qi

Consultant Paediatric Surgeon

NEUROSURGERY

Dr Saiful Azli bin Mat Nayan

Senior Consultant Neurosurgeon

THORACIC SURGERY

Dr Narasimman a/l Sathiamurthy

Consultant Thoracic Surgeon

Dr Narendran a/l Balasubbiah

Thoracic Surgeon

COLORECTAL SURGERY

Dato' Dr. Fitjerald a/l Henry

Senior Consultant Colorectal Surgeon

Dr Norfarizan binti Azmi

Consultant Colorectal Surgeon

UPPER GI SURGERY

Dr Hashimah binti Abdul Rahman

Consultant Upper Gastrointestinal Surgeon

PLASTIC & RECONSTRUCTIVE SURGERY

Dr Ilyasak bin Hussin

Consultant Plastic Surgeon

vi
 ORO-MAXILLOFACIAL SURGERY

Dr Sharifah Tahirah binti Syed Alwi Al-Junid

Senior Consultant Oro-Maxillofacial Surgeon

OTORHINOLARYNGOLOGY

Dr Farid bin Razali

Consultant Otorhinolaryngology Surgeon

OPTHALMOLOGY

Dr Haizul Ikhwan bin Murat

Consultant Ophthalmologist

UROLOGY

Dr Saiful Azli bin Mohd Zainuddin

Senior Consultant Urologist

ANAESTHESIOLOGY

Dr Abu Bakar bin Ahmad

Senior Consultant Anaesthesiologist

Dr Nor Azlin binti Dahlan

Senior Consultant Anaesthesiologist

Dr Amiruddin bin Nik Mohamed Kamil

Senior Consultant Anaesthesiologist

INFECTIOUS DISEASE

Dato' Dr Chow Ting Soo

Senior Consultant Infectious Disease Physician

Dr Anuradha a/p P. Radhakrishnan

Senior Consultant Infectious Disease Physician

INFECTION CONTROL UNIT, MOH

Dr Nor Farah binti Bakhtiar

Senior Principal Assistant Director

vii
SURGICAL & ANAESTHESIA SERVICES UNIT, MOH

Dr Chong Chin Eu
Senior Principal Assistant Director

MEDICAL PROGRAMME, MOH

Dr Suraya binti Amir Husin

Hospital Director

Dr Muhamad Azrin bin Omar

Hospital Deputy Director (2)

MINISTRY OF EDUCATION (MOE)

Prof. Dr Azlina Amir Abbas

Senior Consultant Orthopaedic Surgeon

Prof. Dr Sasheela a/p Sri La Sri Ponnampalavanar

Senior Consultant Infectious Disease Physician

MINISTRY OF DEFENCE

Brig. Jen. Dato' (Dr) Musa bin Kasmin

Senior Consultant Orthopaedic Surgeon

viii
 CONTRIBUTORS

Dato’ Dr Mohammad Anwar Hau Abdullah

Senior Consultant Orthopaedic Surgeon

Dato’ Dr Zakaria bin Zahari

Senior Consultant Paediatric Surgeon

Dr Melor@Mohd Yusof bin Mohd Mansor

Senior Consultant Anaesthesiologist

Dr J. Ravichandran a/l R. Jeganathan

Senior Consultant Obstetrician & Gynaecologist

Dr Andre Das a/l Robert Das

Senior Consultant General Surgeon

Dr Jasiah Binti Zakaria

Senior Consultant Colorectal Surgeon

Dr Louis Ling Leong Liung

Consultant Hepatobiliary Surgeon

Dr Vigneswaran a/l Ramakrishnan

Consultant Gynaecological Oncologist

Dr Abdullah Shamshir bin Abd Mokti

Consultant Internal Medicine Physician

Dr Puteri Fajariah binti Megat Mohd Ghazali

Senior Principal Assistant Director

Dr Nur Mastura binti Aliyasaa'

Senior Principal Assistant Director

Dr Anith Shazwani binti Adnan

Principal Assistant Director

Dr Herbert Leslie
Medical Officer

Dr Muhammad Izmeer bin Apili

Medical Officer

ix
 REVIEWERS

Prof. Dr Keita Morikane

Director, Division of Clinical Laboratory & Infection Control
Yamagata University Hospital, Japan

Prof. Dr Esther A. Saguil

President of the Philippines Surgical Infection Society
Chairman of the Committee on Surgical Infection of the Philippines College of
Surgeons

Dr Nor Hayati binti Ibrahim

Deputy Director
Medical Service Development Section

SECRETARIAT

ADVISOR

Dr Mohd Azman bin Yacob

Director
Medical Development Division

CLINICAL AUDIT UNIT, MOH

Dr Faizah binti Muhamad Zin

Head of Clinical Audit Unit

Dr Zawaniah binti Brukan Ali

Senior Principal Assistant Director

Dr Ahmad Hariz bin Mohamad

Principal Assistant Director

Dr Lavanya a/p Gunasakaran

Principal Assistant Director

Sr Seripah Nor binti Mat Nor

Nursing Sister

x
TABLE OF CONTENTS
Page
PART 1 - INTRODUCTION
Background 1
Objectives 2
Definition of Terms 3
Definition of Operative Period 7
Definition of Type of Surgery 7
Classification of Wound 8

PART 2 - SURGICAL SITE INFECTION (SSI) PREVENTION STRATEGIES

PRE-OPERATIVE
A. Patient Risk Factors
A1 – Age 13
A2 – General Skin Condition 13
A3 – Glycaemic Control 14
A4 – Nutritional Status 16
A5 – Smoking 17
A6 – Obesity 18
A7 – Medications 19
A8 – Immunocompromised State 20
A9 – Staphylococcus Aureus (MSSA and MRSA) Colonisation 21
B. Hospitalisation Factors
B1 – Types of Surgery 23
B2 – Duration of Pre-operative Admission 23
B3 – Pre-operative Bathing or Wiping 24
B4 – Mechanical Bowel Preparation 25

INTRA-OPERATIVE
C1 – Surgical Antibiotic Prophylaxis (SAP) 28
C2 – Draping 30
C3 – Skin Preparation Solution 31
C4 – Hair Removal 32
C5
C5.1 – Operating Room Setup (Traffic) 33
C5.2 – Operating Room Setup (Temperature, Humidity & Ventilation) 34
C6 – Change of Gloves 35
C7 – Hand Washing or Scrubbing 36
C8 – Irrigation 37
C9 – Homeostasis 38
C10 – Antimicrobial-Impregnated Sutures 40
C11 – Wound Dressing 41
C12 – Prophylactic Negative Pressure Wound Therapy (NPWT) 42

xi
 POST-OPERATIVE
D1 – Standard Precautions of Infection Prevention & Control 45
D2 – Patient and Caretaker Education 45
D3 – Surgical Wound Care 46
D4 - Surgical Drain 47

PART 3 - SURVEILLANCE
Introduction 49
Methods 49
Table 1: List of Elective Surgeries for Surveillance 50
Table 2: List of Hospitals for Data Collection 51
Calculation 51
Mechanism of Reporting and Monitoring 52
Table 3: Hospital SSI Committee 52
Table 4: State SSI Committee 53
Table 5: National SSI Committee 54
Flowchart of Mechanism of Reporting and Monitoring 55

PART 4 – WOUND MANAGEMENT

nd
Wound Care Manual, MOH 2 Edition (2023) 59

APPENDIX
Appendix 1 – Withholding Anticoagulants Table
Appendix 2 – SSI Data Collection Form
Appendix 3a – SSI Discharge Leaflet
Appendix 3b – Risalah Discaj Survelan SSI
Appendix 4 – Definitions

xii
List of Abbreviations
AAA Abdominal Aortic Aneurysm
ABHR Alcohol-based Handrub
AC Axillary Clearance
ACH Air Changes per Hour
AMO Assistant Medical Officer
AMR Antimicrobial Resistance
APSIC Asia Pacific Society of Infection Control
ASC Active Surveillance Culture
ASHP American Society of Health-System Pharmacists
AST Active Surveillance Testing
AVF Arteriovenous Fistula
AVR Aortic Valve Replacement
BMI Body Mass Index
BSO Bilateral Salpingo-Oophorectomy
CABG Coronary Artery Bypass Grafting
CAU Clinical Audit Unit
CBGB Coronary Artery Bypass Grafting Surgery with Both Chest and Donor Site
Incisions
CDC Centres for Disease Control and Prevention
3
cfu/m colony forming units per cubic meter
CHG Chlorhexidine Gluconate
CP Contact Precautions
CPRC Crisis Preparedness Response Centre
CT Computed Tomography
DIP Deep Incisional Primary
DIS Deep Incisional Secondary
ECDC European Centre for Disease Prevention and Control
ERAS Enhanced Recovery After Surgery
FDA U.S. Food & Drug Administration
GDFT Goal-Directed Fluid Therapy
HAI Health Care-Associated Infection
HbA1C Glycated Haemoglobin
HCW Healthcare Worker
HIACC Hospital Infection & Antibiotic Control Committee
INR International Normalized Ratio
JCI Joint Commission International
JKKIAK Jawatankuasa Kawalan Infeksi dan Antibiotik Kebangsaan
JKN Jabatan Kesihatan Negeri

xiii
LSCS Lower Segment Caesarean Section
MBP Mechanical Bowel Preparation
mmol/L millimoles per litre
MOABP Mechanical + Oral Antibiotics Bowel Preparation
MOBILE Mechanical and Oral Antibiotic Bowel Preparation versus No Bowel
Preparation for Elective Colectomy
MOH Ministry of Health, Malaysia
MPIS Medical Programme Information System
MRSA Methicillin-Resistant Staphylococcus aureus
m/s metre per second
MSSA Methicillin-Susceptible Staphylococcus aureus
NAG National Antibiotic Guideline
NBP No Bowel Preparation
NCEPOD National Confidential Enquiry into Patient Outcome and Death
NHSN National Healthcare Safety Network
NICE National Institute for Health and Care Excellence
NPWT Negative Pressure Wound Therapy
OMF Oro-Maxillofacial
PIC Person-in-Charge
POCT Point-of-Care Testing
POMR Perioperative Mortality Review
PPS Point-Prevalence Survey
PVP-I Polyvinylpyrrolidone Iodophors/ Povidone Iodine
RCSEng Royal College of Surgeons of England
SAP Surgical Antibiotic Prophylaxis
SDG The United Nations Sustainable Development Goals
SIACC State Infection & Antibiotic Control Committee
SIP Superficial Incisional Primary
SIS Superficial Incisional Secondary
SP Standard Precautions
SSI Surgical Site Infection
S. aureus Staphylococcus aureus
TAH Total Abdominal Hysterectomy
TWG Technical Working Group
UNHCR United Nations High Commissioner for Refugees
USA United States of America
VAS Vascular Access Surgery
WHO World Health Organisation
o
C Degree Celsius

xiv
PART 1 - INTRODUCTION
BACKGROUND

Surgical site infection (SSI) is one of the most common types of healthcare-associated
Infection (HAI). SSI can range from trivial erythema to a life-threatening condition which
may require intensive care or re-operations.

SSI is the most surveyed HAI in low-to-middle income countries and the pooled
incidence of SSI is 11.8 per 100 surgeries1,2. Although it is lower in high-income countries,
it is still the second most frequent HAI in the United States of America (USA) and Europe 1.
SSI is also associated with 3% mortality rate3. However, prevalence studies often
underestimate SSI due to poor recognition and underreporting.

SSI costs an estimated USD$3.3 billion and almost 1 million additional inpatient-days
annually3. The main additional costs are re-operations, nursing, and wound care as well
as drug treatments. The indirect costs are due to loss of productivity, patient
dissatisfaction and litigation, and reduced quality of life for the patient. The United
Nations Sustainable Development Goals 2030, Goal 3: Good Health and Well-being:
Ensure healthy lives and promote well-being for all at all ages, uses SSI rate as a proxy
indicator4.

5
In 2021, the total number of surgeries performed in Malaysia was 891,558 (HIMS) .
Therefore, if our numbers were to be extrapolated based on the statistic above, the total
number of SSI could be as high as 105,203 cases and the number of deaths associated
with SSI could be as high as 3,156. According to the study by Tan LT et. Al. (2019)6,
patients with SSI requires additional hospitalization of 7-10 days. As the cost of additional
inpatient stay is RM 100/ day (Malaysian Fee Schedule 2012)7, which would entail in an
expenditure of at least RM 18 million, excluding the costs of treatment.

The cause of SSI can be multifactorial which include modifiable and non-modifiable
patient, surgical and environmental factors. Therefore, it is essential that healthcare
professionals work towards minimizing the risk of SSI. This is the impetus for preparing
this document in accordance with the recommendations by WHO, CDC and APSIC. This
guideline would also serve as a foundation for an SSI Surveillance Program in Malaysia.

1
OBJECTIVES

General

To provide a reference for healthcare workers in Malaysia for the prevention, diagnosis,
surveillance and management of SSI.

Specific

1. To improve awareness of current measures in SSI prevention

2. To decrease variations in clinical practice

3. To improve the effectiveness of the quality of care

4. To minimize costly preventable complications

5. To serve as an instrument for training

2
DEFINITION OF TERMS

Surgery

Defined as procedure performed for the purpose of structurally altering the human body
by incision or destruction of tissues and is part of the practice of medicine for the
diagnostic or therapeutic treatment of conditions or diseases.

Surgical site

Defined as the site on the human body where the surgery was performed.

Surgical wound1

Defined as a wound created when an incision is made with a scalpel or other sharp cutting
device and then closed in the operating room by suture, staple, adhesive tape, or glue
and resulting in close approximation to the skin edges.

Surgical site infection (SSI)1,8

Defined as an infection related to an operative procedure that occurs at or near the

surgical incision within 30 days of the procedure or within 1 year if prosthetic material is
implanted at surgery.

Also defined as an infection that occurs within 30 days after the operation and involves
the skin and subcutaneous tissue of the incision (superficial incisional) and/or the deep
soft tissue (for example, fascia, muscle) of the incision (deep incisional) and/or any part
of the anatomy (for example, organs and spaces) other than the incision that was opened
or manipulated during an operation (organ/space).

Healthcare worker (HCW)

Defined as any person who is temporarily or permanently employed by or at, or who

serves as a volunteer in, or has an employment contract with, a health care facility.

Medical Implant9

Devices or tissues that are placed inside or on the surface of the body. Many implants
are prosthetic intended to replace missing body part. Other implants deliver medication,
monitor body functions or provide support to organ and tissues1.

3
 3
Surgical Site Infection (SSI) Criteria

Criterion Surgical Site Infection (SSI)

Superficial incisional SSI

Must meet the following criteria:
Date of event occurs within 30 days following the operative procedure
(where day 1 = the procedure date)
AND
involves only skin and subcutaneous tissue of the incision
AND
Patient has at least one of the following:
a. Purulent drainage from the superficial incision
b. Organisms identified from an aseptically-obtained specimen from
the superficial incision or subcutaneous tissues by a culture or non-
culture based on microbiologic testing method which is performed
for purposes of clinical diagnosis or treatment (for example, not
Active Surveillance Culture/Testing [ASC/AST].
c. A superficial incision that is deliberately opened by surgeon,
physician or physician designee and culture or non-culture-based
testing of the superficial incision or subcutaneous tissue is not
performed
AND
Patient has at least one of the following signs or symptoms: localized
pain and tenderness; localized swelling; erythema; or heat.
d. Diagnosis of a superficial incision SSI by a physician* or physician
designee.

* The term physician for the purpose of application of the SSI criteria may
be interpreted to mean a surgeon, infectious disease physician, emergency
physician, other physician on the case, or physician’s designee (nurse
practitioner or physician’s assistant).

Comment There are two specific types of superficial incision SSIs:

1. Superficial Incisional Primary (SIP) – a superficial incisional SSI that
is identified in the primary incision in a patient that has had an
operation with one or more incisions (for example, c-section
incision or chest incision for CBGB).
2. Superficial Incisional Secondary (SIS) – a superficial incisional SSI
that is identified in the secondary incision in a patient that has had
an operation with more than one incision (for example, donor site
incision for CBGB)

4
Reporting The following do not qualify as criteria for meeting the definition of
Instructions for superficial incisional SSI:
Superficial • Diagnosis/ treatment of cellulitis (redness/ warmth/ swelling), by
incisional SSI itself, does not meet superficial incisional SSI criterion ‘d’.
• A stitch abscess alone (minimal inflammation and discharge
confined to the points of suture penetration).
• A localized stab wound or pin site infection; depending on the
depth, these infections might be considered either a skin (SKIN) or
soft tissue (ST) infection.

Note: For an operative procedure, a laparoscopic trocar site is considered

a surgical incision and not a stab wound. If a surgeon uses a laparoscopic
trocar site to place a drain at the end of a procedure this is considered a
surgical incision.

Deep incisional SSI

Must meet the following criteria:
Date of event occurs within 30 following the operative procedure (where
day 1 = the procedure date)
AND
Involves deep soft tissues of the incision (for example, fascial and muscle
layers)
AND
Patient has at least one of the following:
a. Purulent drainage from the deep incision.
b. A deep incision that is deliberately opened or aspirated by a
surgeon, Physician* or physician designee or spontaneously
dehisces
AND
Organisms identified from deep soft tissue of the incision by a
culture or non-culture based on microbiologic testing method
which is performed for purposes of clinical diagnosis or treatment
(for example, not Active Surveillance Culture/ Testing [ASC/ AST]
or culture or non-culture based microbiologic testing method is
not performed. A culture or non-culture-based test from deep soft
tissues of the incision that has a negative finding does not meet
this criterion.
AND
Patient has at least one of the following signs and symptoms:
(>38oC); localized pain or tenderness.
c. an abscess or other evidence of infection involving the deep
incision detected on gross anatomical exam histopathologic exam,
or imaging test.

5
 * The term physician for the purpose of application of the SSI criteria may
be interpreted to mean a surgeon, infectious disease physician, emergency
physician, other physician on the case, or physician’s designee (nurse
practitioner or physician’s assistant).

Comment There are two specific types of deep incisional SSIs:

1. Deep Incisional primary (DIP)- a deep incisional SSI that is identified
in a primary incision in a patient that has had an operation with one
or more incisions (for example, C- section incision or chest incision
for CBGB)
2. Deep Incisional Secondary (DIS) – a deep incisional SSI that is
identified in the secondary incision in a patient that has had an
operation with more than one incision (for example, donor site
incision for CBGB)

Organ/ Space SSI

Must meet the following criteria:
Date of event occurs within 30 following the operative procedure (where
day 1 = the procedure date)
AND
involves any part of the body deeper than the fascial/ muscle layers that is
opened or manipulated during the operative procedure
AND
patient has at least one of the following:
a. purulent drainage from a drain placed into the organ/ space
(for example, closed suction drainage system, open drain, T-
tube drain, CT-guided drainage).
b. organism(s) identified from fluid or tissue in the organ/space
by a culture or non-culture based microbiologic testing
method which is performed for purposes of clinical diagnosis
or treatment (for example, not Active Surveillance Culture/
Testing [ASC/ AST])
c. an abscess or other evidence of infection involving the organ/
space detected on gross anatomical exam or histopathologic
exam, or imaging test evidence definitive or equivocal for
infection.

6
DEFINITION OF OPERATIVE PERIOD

PERIOPERATIVE PERIOD10

It is a period that includes pre-, intra- and post-operative.

a) PRE-OPERATIVE PERIOD*

From the time when patient agrees for operation to arrival of patient at Operating
Room.

b) INTRAOPERATIVE PERIOD*

From arrival of patient at Operating Room until the arrival of patient at the Recovery
Area.

c) POST-OPERATIVE PERIOD*

From arrival of patient at the Recovery Area until completion of surgical care.

*These definitions of terms were based on the consensus of the TWG for the purpose of
standardization of practice within Malaysian healthcare facilities.

DEFINITIONS OF TYPE OF SURGERY11

ELECTIVE SURGERY

Elective surgery is planned surgery that can be booked in advance of routine admission
to hospital as a result of a specialist clinical assessment. It occurs within a planned time
that suits patient, hospital and staff. It is performed in an elective surgical list for
conditions not classified as emergency surgery.11,12,13

7
 1
CLASSIFICATION OF WOUND

An uninfected operative wound in which no inflammation is

encountered and the respiratory, alimentary, genital, or uninfected
Class I urinary tract is not entered. In addition, clean wounds are primarily
Clean closed and, if necessary, drained with closed drainage. Operative
incisional wounds that follow non-penetrating (blunt) trauma should
be included in this category if they meet the criteria.

An operative wound in which the respiratory, alimentary, genital, or

urinary tracts are entered under controlled conditions without
Class II
unusual contamination. Specifically, operations involving the biliary
Clean-
tract, appendix, vagina and oropharynx are included in this category,
contaminated
provided no evidence of infection or major break in technique is
encountered.

Open, fresh, accidental wounds. In addition, operations with major

breaks in sterile technique (e.g. open cardiac massage) or gross
Class III
spillage from the gastrointestinal tract, and incisions in which acute,
Contaminated
non-purulent inflammation is encountered are included in this
category.

Old traumatic wounds with retained devitalized tissue and those that
Class IV involve existing clinical infection or perforated viscera. This definition
Dirty-infected suggests that the organisms causing postoperative infection were
present in the operative field before the operation.

8
REFERENCE

1) Organization, W. H. (2018). Global Guidelines for the Prevention of Surgical Site

Infection.
2) Squeri, R., Genovese, C., Palamara, M. A., Trimarchi, G., & La Fauci, V. (2016).
“Clean care is safer care”: correct handwashing in the prevention of healthcare
associated infections. Annali Di Igiene : Medicina Preventiva E Di Comunità,
28(6), 409–415. doi.org/10.7416/ai.2016.2123
3) Surgical Site Infections (SSI) | OPC | NHSN | CDC.
https://www.cdc.gov/nhsn/opc/ssi/index.html
4) The United Nations Sustainable Development Goals (SDGs), Goal 3 | Department
of Economic and Social Affairs. https://sdgs.un.org/goals/goal3
5) Ministry of Health Malaysia, Hospital Information Management System, Portal
Rasmi Kementerian Kesihatan Malaysia.
https://www.moh.gov.my/index.php/pages/view/129?mid=1581
6) Tan, S., Shiang, F., Wong, J. H., Mat, T. N. a. T., & Gandhi, A. (2019b). A
Prospective Study of Surgical Site Infection in Elective and Emergency General
Surgery in a Tertiary Public Hospital in Malaysia - A Preliminary Report. Madridge
Journal of Surgery. doi.org/10.18689/mjs-1000113
7) Ministry of Health Malaysia, Malaysian Fee Schedule 2012, Portal Rasmi
Kementerian Kesihatan Malaysia.
https://www.moh.gov.my/index.php/pages/view/165?mid=294
8) Surgical site infections. (2017, June 15). European Centre for Disease Prevention
and Control. https://www.ecdc.europa.eu/en/surgical-site-infections
9) Center for Devices and Radiological Health & Center for Devices and Radiological
Health. (2019, September 30). Implants and Prosthetics. U.S. Food and Drug
Administration. https://www.fda.gov/medical-devices/products-and-medical-
procedures/implants-and-prosthetics
10) Ministry of Health Malaysia, Implementation of Perioperative Mortality Review
(POMR), 3rd Edition, 2022, Portal Rasmi Kementerian Kesihatan Malaysia.
https://www.moh.gov.my/index.php/pages/view/2031?mid=708
11) Perioperative Mortality Review (POMR), Prioritisation of Cases for emergency and
Elective Surgery 2018, Portal Rasmi Kementerian Kesihatan Malaysia.
https://www.moh.gov.my/index.php/pages/view/2031?mid=708
12) Alleway, R. (n.d.). Classification of Intervention.
https://www.ncepod.org.uk/classification.html
13) Types of Surgery — Royal College of Surgeons. Royal College of Surgeons.
https://www.rcseng.ac.uk/patient-care/having-surgery/types-of-surgery/

9
PART 2
SSI PREVENTION STRATEGIES
 SSI
PREVENTION
STRATEGIES

PRE-OPERATIVE

INTRA-OPERATIVE

POST-OPERATIVE
PRE – OPERATIVE

11
PATIENT RISK FACTORS
A1 Age

A2 General Skin Condition

A3 Glycemic Control

A4 Nutritional Status

A5 Smoking

A6 Obesity

A7 Medications

A8 Immunocompromised State

A9 Staphylococcus Aureus (MSSA and MRSA) Colonisation

HOSPITALISATION FACTORS
B1 Types of Surgery

B2 Duration of Pre-operative Admission

B3 Pre-operative Bathing or Wiping

B4 Mechanical Bowel Preparation

12
A. PATIENT RISK FACTORS
FACTOR A1 – Age
RECOMMENDATIONS
The TWG recognizes increasing age has an increased risk of SSI.

We recommend that surgeons should exercise caution when dealing with older
surgical patients by optimizing the patients’ condition pre-operatively.

RATIONALE
Increasing age has an increased risk of developing SSI due to deteriorating
immunological responses and presence of possible comorbidities.1

REMARKS / CAVEAT
Older person refers to a person who is over 60 years of age.2,3

REFERENCE
1) Joint Commission International. (2018). Evidence-Based Principles and Practices
for Preventing Surgical Site Infections.
https://store.jointcommissioninternational.org/assets/3/7/JCI_SSI_Toolkit.pdf
2) UNHCR | Emergency Handbook. UNHCR. https://emergency.unhcr.org/
3) World Health Organization: WHO. (2022, October 1). Ageing and health.
https://www.who.int/news-room/fact-sheets/detail/ageing-and-health

FACTOR A2 – General Skin Condition

RECOMMENDATIONS
The TWG identifies that a previous insult to the surgical site increases the risk of SSI.

We recommend when a skin condition is reversible and treatable, the elective surgery
should be postponed until the skin condition is favourable for surgery.

RATIONALE
The presence of previous surgical scar, recent radiotherapy and history of skin or soft
tissue infection to the surgical site increases the risk of SSI.1

REMARKS / CAVEAT
-

REFERENCE
1) Asia Pacific Society of Infection Control. (2018). APSIC guidelines for the
prevention of surgical site infections. Antimicrobial Resistance and Infection
Control. http://apsic-apac.org/wp-content/uploads/2018/05/APSIC-SSI-
Prevention-guideline-March-2018.pdf

13
FACTOR A3 – Glycaemic Control

RECOMMENDATIONS
The TWG recommends having good glycaemic control for both diabetic and non-
diabetic adult patients undergoing surgical procedures to reduce the risk of SSI.1,2

We recommend a target glycaemic control for Diabetic & Non-Diabetic patients (with
risk factors of Diabetes Mellitus) is 8-10mmol/L1,3,4 and insulin infusion should be
considered if blood glucose level is > 10mmol/L.2

The TWG also recommends that post-operative glucose control be maintained from
18 hours post-operatively and “until enteral nutrition” commences to a maximum of
14 days.4

We advise maintaining preoperative HbA1C levels to be less than 8% in diabetic

patients.2

RATIONALE
Poor perioperative blood sugar control increases the risk of SSI.1

Use of available protocols for perioperative blood glucose control for both diabetic
and non-diabetic adult patients undergoing surgical procedures to reduce the risk of
SSI.2

REMARKS / CAVEAT
Glycaemic control in paediatric and adolescent age groups should be considered
separately.

A simple, conventional protocol should be sufficient to reduce the risk of

hypoglycaemia for patients who are admitted to a general ward where frequent
glucose monitoring may not be done.

Recommendations were adapted from the Global Guidelines for The Prevention of
Surgical Site Infection, World Health Organisation (WHO) 2018 & Centres for Disease
Control and Prevention (CDC) Guideline for the Prevention of Surgical Site Infection,
2017 although the quality of evidence is low in the range of optimal perioperative
glucose levels.

14
REFERENCE
1) Asia Pacific Society of Infection Control. (2018). APSIC guidelines for the
prevention of surgical site infections. Antimicrobial Resistance and Infection
Control. http://apsic-apac.org/wp-content/uploads/2018/05/APSIC-SSI-
Prevention-guideline-March-2018.pdf
2) World Health Organization. (2018). Global guidelines for the prevention of
surgical site infection.
3) Berríos-Torres, S. I. et. al. (2017). Centers for Disease Control and Prevention
Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surgery,
152(8), 784. doi.org/10.1001/jamasurg.2017.0904
4) Intensive Care Unit Management Protocol 2018. Welcome to MSIC.
https://www.msic.org.my/guidelines.html

15
FACTOR A4 - Nutritional Status

RECOMMENDATIONS
The TWG recommends optimization of the patient’s nutritional status.1

Patients with malnutrition or at risk of malnutrition following pre-operative nutritional

assessment should receive nutritional support and have their nutrition optimised prior
to a planned surgery.2

RATIONALE
The nutritional status of a patient has an impact on the immune system and hence,
plays a role in the postoperative outcome susceptibility to infection leading to SSI.3,4

It is also reported that malnutrition can delay the healing process and is a threat to the
surgical outcome.5

REMARKS / CAVEAT
Malnutrition is defined as deficiencies, excesses, or imbalances in a person’s intake of
energy and/or nutrients.6

REFERENCE
1) Asia Pacific Society of Infection Control. (2018). APSIC guidelines for the
prevention of surgical site infections. Antimicrobial Resistance and Infection
Control. http://apsic-apac.org/wp-content/uploads/2018/05/APSIC-SSI-
Prevention-guideline-March-2018.pdf
2) Weimann, A., et. al. (2021). ESPEN practical guideline: Clinical nutrition in surgery.
Clinical Nutrition, 40(7), 4745–4761. doi.org/10.1016/j.clnu.2021.03.031
3) Loftus, T. J., Brown, M., Slish, J., & Rosenthal, M. (2019). Serum Levels of
Prealbumin and Albumin for Preoperative Risk Stratification. Nutrition in Clinical
Practice, 34(3), 340–348. doi.org/10.1002/ncp.10271
4) World Health Organization. (2018). Global guidelines for the prevention of
surgical site infection.
5) Joint Commission International. (2018). Evidence-Based Principles and Practices
for Preventing Surgical Site Infections.
https://store.jointcommissioninternational.org/assets/3/7/JCI_SSI_Toolkit.pdf
6) Malnutrition. (2020) https://www.who.int/news-room/questions-and-
answers/item/malnutrition

16
FACTOR A5 – Smoking

RECOMMENDATIONS
The TWG strongly advocates cessation of smoking before surgery.1

We recommend smoking cessation for 3-4 weeks to reduce wound healing

complication2 and to continue cessation of smoking postoperatively.3

RATIONALE
Active smokers have an increased risk of SSI.2

Smoking causes vasoconstriction: hence it delays wound healing. Therefore, it makes

the patient susceptible to the colonization of organisms.3 It also impairs the
revascularization of the wound and delays wound healing.4

Smoking distorts a patient’s immune system and can delay healing, increasing the risk
of infection at the wound site. Smoking just one cigarette decreases the body’s ability
to deliver necessary nutrients for healing after surgery.5

REMARKS / CAVEAT
To reduce respiratory complications, cessation of smoking should be 6-8 weeks.3

Smoking-cessation programs education to patients should be continued.

REFERENCE
1) Asia Pacific Society of Infection Control. (2018). APSIC guidelines for the
prevention of surgical site infections. Antimicrobial Resistance and Infection
Control. http://apsic-apac.org/wp-content/uploads/2018/05/APSIC-SSI-
Prevention-guideline-March-2018.pdf
2) Fan Chiang YH, Lee YW, Lam F, Liao CC, Chang CC, Lin CS. (2022) Smoking
increases the risk of postoperative wound complications: A propensity score-
matched cohort study. Int Wound J. 2023 Feb;20(2):391-402.
doi: 10.1111/iwj.13887. Epub 2022 Jul 9. PMID: 35808947.
3) Wong J, Lam DP, Abrishami A, Chan MT, Chung F. (2012) Short-term
preoperative smoking cessation and postoperative complications: a systematic
review and meta-analysis. Can J Anaesth. 2012 Mar;59(3):268-79.
doi: 10.1007/s12630-011-9652-x. Epub 2011 Dec 21. PMID: 22187226.
4) Joint Commission International. (2018). Evidence-Based Principles and Practices
for Preventing Surgical Site Infections.
https://store.jointcommissioninternational.org/assets/3/7/JCI_SSI_Toolkit.pdf
5) World Health Organization. (2018). Global guidelines for the prevention of
surgical site infection

17
FACTOR A6 - Obesity

RECOMMENDATIONS
The TWG recognizes obesity as a risk factor for developing SSI.

We recommend the HCWs to be vigilant when attending to an obese patient when

planning for surgery. It is advisable and if possible, the patient should undergo a weight
reduction programme prior to surgery.1

RATIONALE
Studies have shown that areas with prominent fatty tissue have a higher rate of
infection due to decreased blood supply which may impair healing.2

REMARKS / CAVEAT
Obesity is defined as a BMI of ≥30.3

Body mass index (BMI) for overweight is defined as 25–29.9.3 Overweight patients
should also be considered for this recommendation.

REFERENCE
1) Asia Pacific Society of Infection Control. (2018). APSIC guidelines for the
prevention of surgical site infections. Antimicrobial Resistance and Infection
Control. http://apsic-apac.org/wp-content/uploads/2018/05/APSIC-SSI-
Prevention-guideline-March-2018.pdf
2) . Joint Commission International. (2018). Evidence-Based Principles and Practices
for Preventing Surgical Site Infections.
https://store.jointcommissioninternational.org/assets/3/7/JCI_SSI_Toolkit.pdf
3) World Health Organization: WHO. (2010, May 6). A healthy lifestyle - WHO
recommendations. https://www.who.int/europe/news-room/fact-sheets/item/a-
healthy-lifestyle-who-recommendations

18
FACTOR A7 – Medications

RECOMMENDATIONS
The TWG suggests identifying the patient’s existing medications which may increase
the risk of SSI (e.g. steroids, chemotherapy, anticoagulant and antiplatelet).1

We recommend withholding anticoagulant and antiplatelet prior to surgery unless

clinically indicated to continue.2

The TWG proposes to continue immunosuppressive medications for its clinical

indication.1 However, in certain condition (e.g. rheumatoid arthritis), the continuation
of medications is based on the CPG and advise of the attending physician3.

We suggest that novel oral anticoagulants e.g. rivaroxaban, dabigatran, apixaban and
edoxaban to be withheld 24-48 hours pre-operatively (refer Appendix 1).2

RATIONALE
Discontinuation of immunosuppressive medications is not recommended for SSI
prevention.1

Withholding anticoagulant and antiplatelet reduces the risk of bleeding and hence
reduces the risk of SSI.2

Surgery can proceed safely if the INR is <1.5 on the day of surgery.2
REMARKS / CAVEAT
-

REFERENCE
1) World Health Organization. (2018). Global guidelines for the prevention of
surgical site infection.
2) Clinical Excellence Commission (2018), Guidelines on Perioperative Management
of Anticoagulant and Antiplatelet Agents
3) Ministry of Health Malaysia (2019), CPG on Management of Rheumatoid Arthritis.

19
FACTOR A8 – Immunocompromised State

RECOMMENDATIONS
The TWG recognises immunocompromised state has an increased risk of SSI.1

We recommend that in these groups of patients, stringent adherence to SSI prevention

measures should be practised.1

RATIONALE
Immunocompromised patients are susceptible to infection from the disease process
as well as the treatment.

REMARKS / CAVEAT
Immunocompromised state includes malignancy, autoimmune diseases, retroviral
disease and etc.

REFERENCE
1) Coccolini, F., et. al. (2021). Surgical site infection prevention and management in
immunocompromised patients: a systematic review of the literature. World
Journal of Emergency Surgery, 16(1). doi.org/10.1186/s13017-021-00375-y

20
FACTOR A9 - Staphylococcus Aureus (MSSA and MRSA)
Colonisation (for indicated elective surgeries)

RECOMMENDATIONS
The TWG suggests screening for Staphylococcus aureus nasal carriage colonization for
indicated elective surgeries (e.g. cardiothoracic, transplant, implant).1

We recommend to perform decolonisation with 2% mupirocin intranasal ointment

regime twice daily + CHG bath or body wash for 5-7 days) if patient is identified as S.
aureus nasal carriage is detected.2

The TWG advises patients with S. aureus to repeat swab after 48 hours of completion
of decolonization.3

The TWG proposes patients with MSSA or MRSA nasal carriage to complete a five-day
decolonization protocol with 2% nasal mupirocin twice per day and daily bathing with
CHG before surgery in their home.1,2
- If MRSA is positive, contact precautions (CPs) were introduced in the operating
room and nursing units, and add Vancomycin to routine/recommended SAP.4,5
- If MSSA, surgical prophylaxis should be adequate to cover for MSSA (i.e.
cefazolin). 4,5

The TWG advocates these recommendations specially to major, clean surgery (such as
cardiothoracic and orthopaedic) involving the insertion of implanted devices.1

RATIONALE
S. aureus nasal colonization is a risk factor for SSI and associated with poor outcomes.

REMARKS
Indicated Elective Surgeries (e.g. cardiothoracic, prosthetic surgery, transplant and
5
implants).

4% CHG bath requires skin contact time of minimum 5 minutes before rinsing.

Alternative decolonization agents are octanidine and povidone iodine.

Cochlear and intra-ocular implants are not included.

21
REFERENCE
1) World Health Organization. (2018). Global guidelines for the prevention of
surgical site infection.
2) Asia Pacific Society of Infection Control. (2018). APSIC guidelines for the
prevention of surgical site infections. Antimicrobial Resistance and Infection
Control. http://apsic-apac.org/wp-content/uploads/2018/05/APSIC-SSI-
Prevention-guideline-March-2018.pdf
3) Tang J, Hui J, Ma J, Mingquan C. (2020) Nasal decolonization of Staphylococcus
aureus and the risk of surgical site infection after surgery: a meta-analysis. Ann
Clin Microbiol Antimicrob. 2020 Jul 30;19(1):33. doi: 10.1186/s12941-020-00376-
w. PMID: 32731866; PMCID: PMC7392830.
4) Septimus EJ. (2019) Nasal decolonization: What antimicrobials are most effective
prior to surgery? Am J Infect Control. 2019 Jun;47S:A53-A57. doi:
10.1016/j.ajic.2019.02.028. PMID: 31146851.
5) Portal Rasmi Kementerian Kesihatan Malaysia. (2018) Perioperative Mortality
Review (POMR), Prioritisation of Cases for emergency and Elective Surgery.
https://www2.moh.gov.my/index.php/pages/view/2031?mid=708

22
B. HOSPITALISATION FACTORS
FACTOR B1 – Types of Surgery
RECOMMENDATIONS
The TWG recognizes that certain types of surgery are associated with higher risk of
SSI.1

We recommend to exercise caution when attending to these cases.

RATIONALE
Types of surgery considered to have higher risk of SSI are:
- complex surgeries
- higher wound classification e.g. class I being a clean wound and class IV being
a dirty infected wound (refer to table in the Introduction section)
- open surgeries
- emergency surgeries

REMARKS / CAVEAT
-
REFERENCE
1) Asia Pacific Society of Infection Control. (2018). APSIC guidelines for the
prevention of surgical site infections. Antimicrobial Resistance and Infection
Control. http://apsic-apac.org/wp-content/uploads/2018/05/APSIC-SSI-
Prevention-guideline-March-2018.pdf

FACTOR B2 – Duration of Pre-operative Admission

RECOMMENDATIONS
The TWG proposes that pre-operative admission should not be more than 2 days.1

RATIONALE
Duration of admissions prior to operation (ideally ≤ 2 days) reduces risk of SSI and
HAIs.2

REMARKS
-
REFERENCE
1) Asia Pacific Society of Infection Control. (2018). APSIC guidelines for the prevention
of surgical site infections. Antimicrobial Resistance and Infection Control.
http://apsic-apac.org/wp-content/uploads/2018/05/APSIC-SSI-Prevention-
guideline-March-2018.pdf
2) Joint Commission International. (2018). Evidence-Based Principles and Practices for
Preventing Surgical Site Infections.

23
FACTOR B3 - Pre-operative Bathing or Wiping

RECOMMENDATIONS
The TWG strongly recommends for pre-operative bathing or wiping on the day of or
prior to the surgery to reduce SSI.1,2

RATIONALE
Patients are advised to bathe (wiping for bedridden patients) prior to surgery (morning
and/ or night before surgery) to reduce bacterial colonization of the skin.1,2

REMARKS / CAVEAT
Soap and water are adequate for bathing or wiping.1

REFERENCE
1) World Health Organization. (2018). Global guidelines for the prevention of
surgical site infection.
2) Asia Pacific Society of Infection Control. (2018). APSIC guidelines for the
prevention of surgical site infections. Antimicrobial Resistance and Infection
Control. http://apsic-apac.org/wp-content/uploads/2018/05/APSIC-SSI-
Prevention-guideline-March-2018.pdf

24
FACTOR B4 – Mechanical Bowel Preparation

RECOMMENDATIONS
The TWG advocates using oral antibiotics along with mechanical bowel preparation
(MBP) in colorectal and related surgeries in adults.1,2,3,4

Mechanical + Oral Antibiotics Bowel Preparation (MOABP) suggested regime:

➔ MBP + oral neomycin 2g + oral metronidazole 2g.3,4

RATIONALE
MBP with oral antibiotics is recommended as it reduces intraluminal bacterial load, thus
decreasing risk of SSI.1,2

MBP alone does not reduce SSI. 1,2,3

REMARKS / CAVEAT
In paediatric patients, the effectiveness of these interventions is yet to be substantiated.

REFERENCE
1) World Health Organization. Global guidelines for the prevention of surgical site
infection. (2018).
2) Asia Pacific Society of Infection Control. (2018). APSIC guidelines for the
prevention of surgical site infections. Antimicrobial Resistance and Infection
Control. http://apsic-apac.org/wp-content/uploads/2018/05/APSIC-SSI-
Prevention-guideline-March-2018.pdf
3) Gustafsson, U., et. al (2018). Guidelines for Perioperative Care in Elective
Colorectal Surgery: Enhanced Recovery After Surgery (ERAS®) Society
Recommendations: 2018. World Journal of Surgery, 43(3), 659–695.
doi.org/10.1007/s00268-018-4844-y
4) Koskenvuo L, et. al. (2019) Mechanical and oral antibiotic bowel preparation
versus no bowel preparation for elective colectomy (MOBILE): a multicentre,
randomised, parallel, single-blinded trial. Lancet. 2019 Sep 7;394(10201):840-848.
doi: 10.1016/S0140-6736(19)31269-3.

25
26
FACTORS

C1 Surgical Antibiotic Prophylaxis (SAP)

C2 Draping

C3 Skin Preparation Solution

C4 Hair Removal

5.1 Operating Room Setup (Traffic)

C5
5.2 Operating Room Setup (Temperature, Humidity & Ventilation)

C6 Change of Gloves

C7 Hand Washing or Scrubbing

C8 Irrigation

C9 Homeostasis

C10 Antimicrobial-Impregnated Sutures

C11 Wound Dressing

C12 Prophylactic Negative Pressure Wound Therapy (NPWT)

27
FACTOR C1 – Surgical Antibiotic Prophylaxis (SAP)

RECOMMENDATIONS
The TWG endorses that the choice of antibiotic should follow the National Antibiotic
Guidelines 3rd edition 2019 - based on the type of surgery.1

The TWG agrees that surgical antibiotic prophylaxis is administered in order to provide
a concentration of the drug in serum and tissues that is at a bactericidal level when the
incision is made.2,3

We recommend re-dosing if the duration of surgery exceeds the half-life of the

antibiotic and/ or the presence of other factors that may shorten the half-life of the
drug (e.g. burns, excessive blood loss >1.5L). 2,3

Timing of antibiotic given should be within 30-60 minutes before incision. However,
for Fluoroquinolones & Vancomycin which require infusion, the antibiotics have to be
administered 2 hours before incision.

In procedures requiring tourniquet, the SAP needs to be administered at least 15

minutes prior to inflation of the tourniquet.6

RATIONALE
Single dose of prophylaxis is sufficient to reduce SSI and prolonged use is not proven
to reduce SSI instead it increases AMR and cost.2

Meta-analyses and Systemic Reviews of 52 Randomised Control Trials showed no

evidence for a benefit of postoperative continuation of antibiotic prophylaxis over its
discontinuation in reducing the incidence of SSI.4,5

REMARKS
While single dose prophylaxis is usually sufficient, the duration for antibiotics in
procedures involving implants should not be more than 24 hours, whilst, for cardiac
surgery, it should not be more than 48 hours. This is to minimise adverse effects,
prevent AMR and is cost-effective.4,5

28
REFERENCE
1) National Antimicrobial Guideline (NAG) (2019), 3rd Edition. Pharmaceutical
Services Programme. https://www.pharmacy.gov.my/v2/en/documents/national-
antimicrobial-guideline-nag-2019-3rd-edition.html
2) World Health Organization. (2018). Global guidelines for the prevention of surgical
site infection.
3) Joint Commission International. (2018). Evidence-Based Principles and Practices for
Preventing Surgical Site Infections.
https://store.jointcommissioninternational.org/assets/3/7/JCI_SSI_Toolkit.pdf
4) SW de Jonge, et. al. (2020) Effect of postoperative continuation of antibiotic
prophylaxis on the incidence of surgical site infection: a systematic review and
meta-analysis. Lancet Infect Dis. 2020 Oct;20(10):1182-1192. doi: 10.1016/S1473-
3099(20)30084-0. Epub 2020 May 26. PMID: 32470329.
5) Bratzler DW, Dellinger EP, Olsen KM, et al. (2013) Clinical practice guidelines for
antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm. 2013; 70:195–283
6) Nagata K, Yamada K, Shinozaki T, et al. (2022) Effect of Antimicrobial Prophylaxis
Duration on Health Care–Associated Infections After Clean Orthopedic Surgery: A
Cluster Randomized Trial. JAMA Netw Open.2022;5(4): e226095.
doi:10.1001/jamanetworkopen.2022.6095

29
FACTOR C2 - Draping

RECOMMENDATIONS
The TWG recommends using either sterile disposable non-woven or sterile reusable
woven drapes and surgical gowns during surgical operations.1,2

For ophthalmic surgeries, the TWG acclaims proper draping of the eyelid margin using
adhesive non-porous drape and the use of speculum to cover all the eyelashes.3

RATIONALE
Ideally, drapes should be impermeable to blood, other bodily fluids as well as any other
fluids used during surgery; resistant to tears, punctures, and abrasions. This is to ensure
the integrity of the sterile field. They should be consistent with accepted flammability
standards. Drapes should also be durable, flexible, and low-linting, while having limited
memory. 1,2

REMARKS
Safety and financial aspects as well as ecological effects should always be considered
when selecting drapes and gowns.

REFERENCE
1) Joint Commission International. (2018). Evidence-Based Principles and Practices for
Preventing Surgical Site Infections.
https://store.jointcommissioninternational.org/assets/3/7/JCI_SSI_Toolkit.pdf
2) World Health Organization. (2018). Global guidelines for the prevention of surgical
site infection.
3) Ministry of Health, Malaysia. (2006) Management of Post-operative Infectious
Endophthalmitis.

30
FACTOR C3 – Skin Preparation Solution

RECOMMENDATIONS
The TWG recommends the use of Alcohol-based antiseptic solutions for surgical site
skin preparation in patients undergoing surgical procedures.1,2
The options are1,2:
1) Chlorhexidine / chlorhexidine gluconate (CHG): 0.5 - 4% CHG in 70 -74% Alcohol
with contact time as recommended by the manufacturer,
Or
2) Povidone iodophore with alcohol 70% with contact time as recommended by
the manufacturer,
Or
3) Aqueous povidone iodophore with at least 2-minute contact time followed by
alcohol 70% and let air dry.
In ophthalmic surgeries, the use of povidone 5% is recommended for the preparation
of skin and conjunctival sac.3

RATIONALE
Skin preparation solution is used to reduce skin flora thus minimize risk of SSI. Dual
agent containing alcohol and CHG or PVP-I would provide rapid, persistent and
cumulative antimicrobial action.
The contact and drying time are essential for bactericidal effect. Additionally, allowing
alcohol to air dry reduces the risk of operating room fires. 1,2

REMARKS
When selecting a skin antiseptic agent, consider the following qualities:
• Non-irritant,
• Broad-spectrum activity,
• Ability to act rapidly,
• Persistent effect,
• Resistance to being washed away or inactivated by blood and/ or other fluids.

REFERENCE
1) Joint Commission International. (2018). Evidence-Based Principles and Practices
for Preventing Surgical Site Infections.
https://store.jointcommissioninternational.org/assets/3/7/JCI_SSI_Toolkit.pdf
2) Asia Pacific Society of Infection Control. (2018). APSIC guidelines for the
prevention of surgical site infections. Antimicrobial Resistance and Infection
Control. http://apsic-apac.org/wp-content/uploads/2018/05/APSIC-SSI-
Prevention-guideline-March-2018.pdf
3) Ministry of Health, Malaysia. (2006) Management of Post-operative Infectious
Endophthalmitis.

31
FACTOR C4 – Hair Removal

RECOMMENDATIONS
The TWG strongly recommends against removal of hair unnecessarily.1,2,3

However, if needed, hair removal with a clipper should be performed as close as

possible to incision time and only the necessary area.1

RATIONALE
Shaving, plucking, threading or waxing is strongly discouraged at all times due to
micro-trauma to the skin leading to bacterial multiplication. Usage of depilatory cream
may cause an allergic reaction in some individuals. These hair removal techniques have
been shown to increase the risk of SSI.1,2

REMARKS / CAVEAT
-

REFERENCE
1) World Health Organization. Global guidelines for the prevention of surgical site
infection. (2018).
2) Berríos-Torres, S. I. et. al. (2017). Centers for Disease Control and Prevention
Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surgery, 152(8),
784. doi.org/10.1001/jamasurg.2017.0904
3) Asia Pacific Society of Infection Control. (2018). APSIC guidelines for the
prevention of surgical site infections. Antimicrobial Resistance and Infection
Control. http://apsic-apac.org/wp-content/uploads/2018/05/APSIC-SSI-
Prevention-guideline-March-2018.pdf

32
FACTOR C5.1 – Operating Room Setup (Traffic)

RECOMMENDATIONS
The TWG advises to keep the number of personnel in operating room to a minimum
without compromising the surgery.1

We recommend keeping the movement in and out of the operating room to a

minimum from the time instruments are laid out until the wound is closed.2

RATIONALE
Managing traffic flow is to reduce air turbulence that disrupts surface particulates which
may contain micro-organisms.

Adequate working space may reduce risk of SSI.

It is important to control number of HCWs, traffic and activities in operating theatre as

the number of people and the amount of activity influence the number of
microorganisms present and therefore influence the risk of infection.2

REMARKS
-

REFERENCE
1) Asia Pacific Society of Infection Control. (2018). APSIC guidelines for the prevention
of surgical site infections. Antimicrobial Resistance and Infection Control.
http://apsic-apac.org/wp-content/uploads/2018/05/APSIC-SSI-Prevention-
guideline-March-2018.pdf
2) Ministry of Health, Malaysia. (2019) KKM Policies & Procedures on Infection
Prevention and Control. Medical Developement Division.
https://www.moh.gov.my/moh/press_releases/KKM%20Policies%20&%20Procedures
%20on%20Infection%20Prevention%20and%20Control%202019.pdf

33
FACTOR C5.2 - Operating Room Setup (Temperature, Humidity &
Ventilation)

RECOMMENDATIONS
The TWG recommends maintaining the Operating Room temperature, humidity and
ventilation as in the table below:1

Types of Air Room air

Flow rate Temperature
Operating Humidity Sampling changes
(m/s) (oC)
Theatre (cfu/m3) (ACH)
Conventional 50-60% <10 15-25 0.65 – 0.75 18-22
Ultraclean 50-60% <1 >25 0.2 16-21

RATIONALE
The temperature and humidity are measured to prevent the growth of moulds and
fungi to reduce the risk of SSI.2

REMARKS
-

REFERENCE
1) Ministry of Health, Malaysia. (2019) KKM Policies & Procedures on Infection
Prevention and Control. Medical Development Division.
https://www.moh.gov.my/moh/press_releases/KKM%20Policies%20&%20Procedures
%20on%20Infection%20Prevention%20and%20Control%202019.pdf
2) Joint Commission International. (2018). Evidence-Based Principles and Practices for
Preventing Surgical Site Infections.
https://store.jointcommissioninternational.org/assets/3/7/JCI_SSI_Toolkit.pdf

34
 FACTOR C6 – Change of Gloves

RECOMMENDATIONS
The TWG recommends changing of gloves during the operation.1
1) when the gloves are visibly soiled or torn, or
2) when changing from dirty to clean surgery on the same patient, or
3) before insertion of implants

We advise double-gloving for surgeries based on universal precaution for infection.1,2

RATIONALE
The risk of micro-perforations is higher with longer surgical time. Double gloving has
been shown to reduce the risk of contamination in the event of micro-perforations.1

REMARKS
-

REFERENCE
1) National Institute for Health and Care Excellence (NICE). (2020). Surgical site
infections: prevention and treatment.
https://www.nice.org.uk/guidance/ng125/resources/surgical-site-infections-
prevention-and-treatment-pdf-66141660564421
2) Healthcare Providers | Hand Hygiene | CDC.
https://www.cdc.gov/handhygiene/providers/index.html

35
FACTOR C7 – Hand Washing or Scrubbing

RECOMMENDATIONS
The TWG recommends that all members of the surgical team must perform a surgical
hand scrub before donning sterile gowns and gloves for surgical procedures with:1,2

1. Water & antiseptic solution:

• Polyvinylpyrrolidone iodophors (PVP-I) scrub solution
• Chlorhexidine gluconate (CHG) scrub solution

Or

2. Alcohol based hand rub (ABHR):

• CHG solution plus ethyl alcohol
• Ethanol plus isopropanol

RATIONALE
Hand washing/ scrubbing minimises the risk for SSI by reducing the microbial skin
count to a minimum, while leaving a long-acting antimicrobial residue.

REMARKS
Brush is only used for cleaning nails if necessary.

Usage of the above solutions as per manufacturers’ recommendation.

REFERENCE
1) Ministry of Health, Malaysia. (2019) KKM Policies & Procedures on Infection
Prevention and Control. Medical Development Division.
https://www.moh.gov.my/moh/press_releases/KKM%20Policies%20&%20Procedures
%20on%20Infection%20Prevention%20and%20Control%202019.pdf
2) Joint Commission International. (2018). Evidence-Based Principles and Practices for
Preventing Surgical Site Infections.
https://store.jointcommissioninternational.org/assets/3/7/JCI_SSI_Toolkit.pdf

36
FACTOR C8 - Irrigation

RECOMMENDATIONS
The TWG recommends the use of aqueous povidone-iodine (PVP-I) solution irrigation
of the incisional wound (skin) before closure for the purpose of preventing SSI,
particularly in clean and clean contaminated wounds.1,2

Alternatively, a saline irrigation is a suitable substitute when the use of PVP-I is

contraindicated.1

The TWG is against the use of antibiotic incisional wound irrigation for any surgeries.2

RATIONALE
Irrigation of the incisional wound with an aqueous PVP-I solution is beneficial in
reducing the risk of SSI when compared to irrigation with a saline solution.

Antibiotic irrigation may increase the emergence of AMR.

REMARKS
Insufficient evidence to recommend for or against saline irrigation of incisional wounds
before closure for the purpose of preventing SSI.

Based on in-vitro studies, there is a concern about the potential toxic effects of PVP-I
on fibroblasts, mesothelium and the healing of tissue. Hence, diluting the PVP-I is an
option to reduce this risk.

REFERENCE
1) Asia Pacific Society of Infection Control. (2018). APSIC guidelines for the prevention
of surgical site infections. Antimicrobial Resistance and Infection Control.
http://apsic-apac.org/wp-content/uploads/2018/05/APSIC-SSI-Prevention-
guideline-March-2018.pdf
2) World Health Organization. (2018). Global guidelines for the prevention of surgical
site infection.

37
 *
FACTOR C9 – Homeostasis

*Homeostasis includes Normothermia, Normovolemia, Oxygenation and

Normoglycemia**.
*Homeostasis is to be maintained in the entire perioperative period (Pre-operatively,
Intra-operatively & Post-operatively)
** For Glycemic Control refer Factor A3 in Pre-Operative Factor

RECOMMENDATIONS
The TWG recommends to maintain the patient’s homeostasis as below:
- Body temperature is maintained between 36.5°C to 37.5°C.1,2,3
- Goal-Directed Fluid Therapy (GDFT) is recommended to maintain
normovolemia.3,4,5
- Maintain SpO2 > 95% intra-operatively with basic standard monitoring.3,1,6

The TWG advises for continuation of measures to prevent hypothermia post-

operatively.

We recommend maintaining optimal oxygenation even during recovery period to

ensure that haemoglobin oxygen saturation (SpO2) of more than 95%.

RATIONALE
Careful monitoring of the oxygen level is part of the overall strategy to maintain
patient’s homeostasis. This includes normovolaemia, normoglycaemia and
normothermia to reduce the risk of infection throughout the perioperative phase.

a) Normothermia
- Perioperative hypothermia, which is common during major surgeries, may
increase the risk for SSI.

b) Normovolaemia
- Normovolaemia prevents peripheral vasoconstriction to ensure adequate tissue
perfusion. Therefore, local immunity is preserved and wound healing is
improved.3
- Perioperative fluid therapy prevents tissue hypoxia by maximizing the cardiac
output and thus improving arterial oxygenation.
- Adequacy of tissue perfusion can be monitored by various means including
Point-of-care testing (POCT) to optimize tissue oxygenation.

c) Oxygenation
- Good oxygenation promotes wound healing.
- Adequate wound tissue oxygenation can trigger healing responses and
favourably influence the outcome of other treatment modalities.

38
REMARKS
a) Normothermia
- Normothermia is to be maintained except for surgical procedures where
hypothermia is required (e.g. Heart and aortic surgery).3
- Optimizing blood flow to the surgical incision reduces SSI rates through the avoidance
of hypothermia.
- Normal core body temperature is 36.0 - 37.5 °C.6
- Recommended pre-operative core temperature 36.5 – 37.5 degree Celsius.6

b) Normovolaemia
- GDFT refers to a haemodynamic treatment based on the titration of fluid and
inotropic agents according to cardiac output or similar parameters.
- Normovolemia can be assessed and monitored by urinary output, serum
markers or other methods (e.g. central venous pressure monitoring etc.).

REFERENCE
1) Joint Commission International. (2018). Evidence-Based Principles and Practices for
Preventing Surgical Site Infections.
https://store.jointcommissioninternational.org/assets/3/7/JCI_SSI_Toolkit.pdf
2) National Institute for Health and Care Excellence (NICE). (2020). Surgical site
infections: prevention and treatment.
https://www.nice.org.uk/guidance/ng125/resources/surgical-site-infections-
prevention-and-treatment-pdf-66141660564421
3) World Health Organization. (2018). Global guidelines for the prevention of surgical
site infection.
4) Asia Pacific Society of Infection Control. (2018). APSIC guidelines for the prevention
of surgical site infections. Antimicrobial Resistance and Infection Control.
http://apsic-apac.org/wp-content/uploads/2018/05/APSIC-SSI-Prevention-
guideline-March-2018.pdf
5) Berríos-Torres, S. I. et. al., (2017). Centers for Disease Control and Prevention
Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surgery, 152(8),
784. doi.org/10.1001/jamasurg.2017.0904
6) National Institute for Health and Care Excellence (NICE). (2020). Surgical site
infections: prevention and treatment.
https://www.nice.org.uk/guidance/ng125/resources/surgical-site-infections-
prevention-and-treatment-pdf-66141660564421

39
FACTOR C10 - Antimicrobial-impregnated sutures

RECOMMENDATIONS
The TWG advises that the antimicrobial-impregnated sutures may be considered as a
strategy to prevent SSI.

However, where there are high SSI rates, in spite of basic preventive measures,
individual centres should consider the use of antimicrobial-impregnated sutures.1,2

RATIONALE
Antimicrobial-impregnated sutures showed benefit in reducing SSI rates in patients
undergoing surgical procedures when compared to non-coated sutures however the
evidence was moderate to low.

REMARKS
-

REFERENCE
1) World Health Organization. (2018). Global guidelines for the prevention of surgical
site infection.
2) Asia Pacific Society of Infection Control. (2018). APSIC guidelines for the
prevention of surgical site infections. Antimicrobial Resistance and Infection
Control. http://apsic-apac.org/wp-content/uploads/2018/05/APSIC-SSI-
Prevention-guideline-March-2018.pdf

40
 FACTOR C11 - Wound Dressing

RECOMMENDATIONS
The TWG recommends dressings used on primarily closed surgical wounds should be
sterile and should be applied with an aseptic technique.1,2

The dressings applied in the operating theatre are generally allowed to remain on the
wound for 48 to 72 hours or when indicated. 1,2

We emphasise the usage of advanced dressings is dependent on the patient’s risk for
SSI and cost-consideration.

RATIONALE
Evidence shows that in primarily-closed wounds, advanced dressings do not offer an
advantage in preventing SSI over standard dressings.

REMARKS
Advanced dressings refer to occlusive types of dressing materials such as hydrocolloid,
hydro active, silver-containing, metallic or ionic dressing and polyhexamethyline
biguanide dressings.

Negative Pressure Wound Therapy (NPWT) falls under a different category and
considered separately.

REFERENCE
1) Joint Commission International. (2018). Evidence-Based Principles and Practices for
Preventing Surgical Site Infections.
https://store.jointcommissioninternational.org/assets/3/7/JCI_SSI_Toolkit.pdf
2) World Health Organization. (2018). Global guidelines for the prevention of surgical
site infection.

41
FACTOR C12 - Prophylactic Negative Pressure Wound Therapy
(NPWT)

RECOMMENDATIONS
The TWG does not recommend a routine use of NPWT for primarily-closed wounds
except in high-risk wounds for SSI. 1

RATIONALE
Evidence shows that prophylactic NPWT has a benefit in reducing the risk of SSI in
patients with a primarily closed surgical incision following high-risk wounds (e.g. in
case of poor tissue perfusion due to soft tissue and skin damage, decreased blood
flow, dead space and intra-operative contamination).1,2

REMARKS
NPWT is expensive and may not be available in some centres.

REFERENCE
1) World Health Organization. (2018). Global guidelines for the prevention of surgical
site infection.
2) Asia Pacific Society of Infection Control. (2018). APSIC guidelines for the
prevention of surgical site infections. Antimicrobial Resistance and Infection
Control. http://apsic-apac.org/wp-content/uploads/2018/05/APSIC-SSI-
Prevention-guideline-March-2018.pdf

42
43
FACTORS

D1 Standard Precautions of Infection Prevention & Control

D2 Patient and Caretaker Education

D3 Surgical Wound Care

D4 Surgical Drain

44
FACTOR D1 - Standard Precautions of Infection Prevention & Control

RECOMMENDATIONS
The TWG recommends maintaining the components of Standard Precautions of
Infection Prevention & Control at all times pertaining to SSI, which include:1,2
• hand hygiene,
• personal protective equipment,
• disinfection & sterilization,
• environmental hygiene,

RATIONALE
Compliance of the Standard Precautions may reduce complications and risk of SSI.

REMARKS
-

REFERENCE
1) Ministry of Health, Malaysia. KKM Policies & Procedures on Infection Prevention
and Control (2019) Medical Development Division.
https://www.moh.gov.my/moh/press_releases/KKM%20Policies%20&%20Procedures
%20on%20Infection%20Prevention%20and%20Control%202019.pdf
2) World Health Organization (2017). Global Guidelines for the Prevention of Surgical
Site Infection.

FACTOR D2 - Patient and Caretaker Education

RECOMMENDATIONS
The TWG emphasizes on patient and caretaker education regarding wound care and
in identifying potential or early signs of SSI.1,2

RATIONALE
Providing adequate information and education to the patient and family may reduce
complications and risk of SSI.

REMARKS
-

REFERENCE
1) Joint Commission International. (2018). Evidence-Based Principles and Practices for
Preventing Surgical Site Infections.
https://store.jointcommissioninternational.org/assets/3/7/JCI_SSI_Toolkit.pdf
2) Ministry of Health, Malaysia (2023), Wound Care Manual 2nd edition

45
FACTOR D3 - Surgical Wound Care

RECOMMENDATIONS
The TWG recommends that HCWs should be trained and educated in wound care as
well as in signs and symptoms of infection.1,2

We advise for HCWs to be able to identify and treat the surgical wound in case of an
SSI or to refer to the relevant teams for an optimal management.1

RATIONALE
Proper wound management education and training to the HCWs may prevent wound
contamination, potential of SSI and its complications.

REMARKS
Management of wound (i.e. wound care) is based on the type of wounds.

REFERENCE
1) Joint Commission International. (2018). Evidence-Based Principles and Practices for
Preventing Surgical Site Infections.
https://store.jointcommissioninternational.org/assets/3/7/JCI_SSI_Toolkit.pdf
2) Ministry of Health, Malaysia (2023), Wound Care Manual 2nd edition

46
FACTOR D4 - Surgical Drain

RECOMMENDATIONS
The TWG recommends against the routine use of surgical drains.

However, in certain surgeries where post-operative surgical drain is required, regular

inspection of the drain and the drain site must be done to ensure that it is functioning
properly and there are no signs of infection1,2.

We advise removing the drain when clinically indicated.

The TWG emphasizes the presence of a drain is not an indication to prolong the usage
of prophylactic antibiotic2.

RATIONALE
A drain can be a source of infection and may prolong the unnecessary usage of
antibiotics.

REMARKS
Wound drains are single-use devices and must not be reused.

REFERENCE
1) World Health Organization. (2018). Global guidelines for the prevention of surgical
site infection.
2) Joint Commission International. (2018). Evidence-Based Principles and Practices
for Preventing Surgical Site Infections.
https://store.jointcommissioninternational.org/assets/3/7/JCI_SSI_Toolkit.pdf

47
PART 3 - SURVEILLANCE
 INTRODUCTION

CDC defines surveillance as the ongoing and systematic collection, analysis, and
interpretation of health data in the process of describing and monitoring a health event. This
information is used for planning, implementing, and evaluating interventions and programs1.

SSI monitoring requires active, patient-based prospective surveillance. Till date, Malaysia
does not have an SSI surveillance programme in place. Based on the requirements at a global
and national level, there is a pressing need for a national SSI Surveillance programme.

To kick start the initiative, the TWG has convened to focus on elective surgeries only in all
MOH hospitals. Once the surveillance is well established, the programme will then be
expanded in future to include emergency surgeries and other hospitals nationwide (public
and private hospitals).

METHODS

All patients who have undergone the elective surgeries (Table 1) will be accounted for in the
surveillance, regardless of prolonged hospitalisation, readmission or outpatient, emergency
department and private centre visits. These patients, will be educated upon discharge to
identify SSI and will be provided with a discharge leaflet containing information on early
signs and symptoms of SSI as well as to inform or to be referred back to the operating
hospitals in the event of an SSI. This mechanism is in place to minimise underreporting of
cases especially for superficial SSIs.

Below are the inclusion and exclusion criteria for this surveillance programme:
I. Inclusion Criteria
- Infection of surgical wound occurring within 30-days post-surgery (without
implant) or within 90-days* post-surgery (with implant).
- Inpatient elective surgeries by the respective fraternity as listed in Table 1 in the
participating hospitals (pilot) as listed in Table 2**.

*Although the definition for SSI in surgeries with implants is up to 1 year, but for the purpose
of this surveillance, we are only monitoring till 90-days.
**For the purpose of this surveillance, data will be collected only from the selected hospitals
in the list below. However, all MOH hospitals are expected to monitor their SSI rates based
on this guideline.

II. Exclusion Criteria

- Emergency surgeries (except paediatric semi-emergency vascular access surgeries
(VAS))
- Day-care (except ophthalmology cataract surgeries), outpatient and procedure
room surgeries
- SSI not related to the primary surgery

49
Table 1
2,3
List of Elective Surgeries for Surveillance*
Duration of
Discipline Types of Surgery
Surveillance
Colectomy +/- proctocolectomy 30 days
General surgery / Mastectomy +/- axillary clearance 90 days
Colorectal / Breast & Hernioplasty 90 days
Endocrine Surgery Thyroid surgeries 30 days
Elective laparoscopic/ open cholecystectomy 30 days
Primary Hip Arthroplasty 90 days
Orthopaedic Surgery
Primary Knee Arthroplasty 90 days
Neurosurgery Elective Craniotomy 90 days
Pull-through Procedure (open / laparoscopic) 30 days

Paediatric Surgery* Vascular Access Surgery (surgical incision only)

* including all Vascular Access Surgeries done 30 days
in semi-emergency list
All Elective Surgery (including elective
Hepatobiliary Surgery 30 days
transplant)
Open Cystectomy 30 days
Urology
Open Nephrectomy 30 days
Open AAA Repair 30 days
Vascular Surgery
Renal Access Surgery (i.e. AVF) 30 days
90 days
Primary CABG (Sternal & Harvest Site) (both chest and
Cardiothoracic Surgery
donor sites)
Aortic Valve Replacement Surgery 90 days
Thoracic Surgery Lung Lobectomy 30 days
Cleft Lip Repair 30 days
Plastic Surgery Flap Donor Site 30 days
Full Thickness Skin Graft Donor Site 30 days
Open Total Abdominal Hysterectomy (TAH)
30 days
Obstetrics & +/-Bilateral Salpingo-Oophorectomy (BSO)
Gynaecology Elective Lower Segment Caesarean Sections
30 days
(LSCS)
Parotidectomy 30 days
Submandibulectomy 30 days
Neck Dissection 30 days
Otorhinolaryngology Sistrunk Surgery (Excision of Thyroglossal cyst) 30 days
Excision of Branchial cyst 30 days
Thyroidectomy 30 days
Ear Surgery - Cochlea Implant 90 days
Minor Oral Surgery 30 days
30 days
Oromaxillofacial Surgery
Elective Oral & Maxillofacial trauma surgery 90 days
(with implant)
Ophthalmology
(all cataract surgeries
done in day-care (as per Cataract 30 days
Ophthalmology National
Registry))
*This list may be amended from time to time, based on the fraternity and HOS preference.

50
Table 2
List of Pilot Hospitals for Data Collection and Reporting (Surveillance)

State Pilot Hospitals

Perlis Hospital Tuanku Fauziah, Perlis
Hospital Sultanah Bahiyah, Alor Setar
Kedah
Hospital Sultan Abdul Halim, Sungai Petani
Hospital Pulau Pinang
Pulau Pinang
Hospital Seberang Jaya
Perak Hospital Raja Permaisuri Bainun, Ipoh
Hospital Taiping
Hospital Kuala Lumpur
Wilayah Persekutuan Kuala Lumpur
Hospital Tunku Azizah, Kuala Lumpur
Wilayah Persekutuan Putrajaya Hospital Putrajaya
Hospital Tengku Ampuan Rahimah, Klang
Hospital Sungai Buloh
Selangor Hospital Selayang
Hospital Serdang
Hospital Shah Alam
Negeri Sembilan Hospital Tuanku Ja’afar, Seremban
Melaka Hospital Melaka
Hospital Sultanah Aminah, Johor Bahru
Johor
Hospital Sultan Ismail, Johor Bahru
Hospital Tengku Ampuan Afzan, Kuantan
Pahang
Hospital Sultan Haji Ahmad Shah, Temerloh
Hospital Sultanah Nur Zahirah, Kuala Terengganu
Terengganu
Hospital Kemaman
Kelantan Hospital Raja Perempuan Zainab II, Kota Bharu
Hospital Umum Sarawak, Kuching
Sarawak
Pusat Jantung Sarawak
Hospital Queen Elizabeth I, Kota Kinabalu
Sabah Hospital Queen Elizabeth II, Kota Kinabalu
Hospital Wanita & Kanak-Kanak Sabah, Likas
Wilayah Persekutuan Labuan Hospital Labuan

CALCULATION

The SSI rate is determined by the formula below:

Number of SSI in the Selected Surgery

___________________________________ X 100%
Total Number of Selected Surgery*

- Calculation of the SSI rate should comprise of the fraternity SSI rate and the individual
SSI rate of each type of surgery in the fraternity.
- The elective surgery is based on the fraternity or discipline’s Elective list that provide the
service (e.g. if an elective nephrectomy is done by General Surgery, it is not included in
the SSI calculation for the time being).

*The total number of selected surgery should be obtained from the OT Elective List/ OT Book.
51
MECHANISM OF REPORTING AND MONITORING

HOSPITAL
Each department must appoint a minimum of one (1) PIC who should be a Medical Officer.
The PIC’s tasks are:
i) to identify the patients who are going for the selected elective surgeries
ii) to ensure that the SSI Data Collection Form (Appendix 1) is attached to the patient’s
operative file and completed perioperatively (pre, intra and post-operatively)
iii) to collect and compile the SSI Data Collection Form upon discharge of the patient
iv) to keep record of the denominator (number of elective surgery) in the Google Sheet
v) to enter the data from the SSI Data Collection Form into the SSI Module in the MPIS
system
vi) to ensure that the patients who have undergone these surgeries are educated on the
early signs and symptoms of SSI
vii) to ensure that these patients are discharged with the SSI Surveillance Discharge
Leaflet (Appendix 2a and 2b)
viii) to report identified SSI cases into the SSI Module in the MPIS System once the case
has been verified by a surgeon in the department.

In order for the surveillance implementation to be effective, each hospital must have their
own SSI Committee which will be chaired by the Hospital Deputy Director and consists of
members from all surgical-based departments as well as Anaesthesiologist, Infectious
Diseases Physician (if available), Hospital Quality Officer, Hospital Infection Control
representative, Hospital Wound Care Committee representative, Nursing representative,
Assistant Medical Officer (AMO) and Pharmacist (Table 3).

Table 3
Hospital SSI Committee
Position Committee Members No. of representatives
Advisor Hospital Director 1
Chairperson Hospital Deputy Director* 1
Deputy HOD/ Senior Consultant Surgeon**
1
Chairperson (Surgical Based Discipline)
Secretariat Hospital Quality or Infection Control Officer*** 1
1
Surgeons from All Surgical Disciplines
(from each discipline)
Anaesthesiologist 1
Infectious Disease Physicians (if available) 1
Department Person In-Charged (PIC) 1
Member Hospital Infection Control Representative 1
Hospital Quality Unit Representative 1
Hospital Wound Care Representative 1
Nursing Representative 1
Assistant Medical Officer (AMO) 1
Pharmacist 1
*/**/*** appointed by the Hospital Director

52
The Hospital Quality Officer or Infection Control Officer tasks are:
i) as the Secretariat for Hospital SSI Committee (appointed by the Hospital Director).
ii) to monitor, compile and analyse the data from the MPIS System on a monthly basis.
iii) to coordinate Hospital SSI Committee meetings biannually.
iv) to present the analysis of SSI data including identified issues as well as
recommendations from the Hospital SSI committee during the Hospital Infection &
Antibiotics Control Committee (HIACC) meeting.
v) to give feedback of the analysis and the HIACC meeting to the Departments involved
as well as the JKN.

STATE
Concurrently, each JKN must have their own State SSI Committee which will be chaired by
the State Deputy Director and consists of members from all surgical-based State Chief
Surgeons and Anaesthesiologist, State Infectious Diseases Physician (if available), State
Quality Officer, State Infection Control representative, State Wound Care Committee
representative, Nursing representative, Assistant Medical Officer (AMO) and Pharmacist
(Table 4).

Table 4
State SSI Committee
No. of
Position Committee Members
representatives
Advisor State Health Director 1
Chairperson Deputy State Health Director (Medical) 1
Deputy Chairperson State Chief Surgeon (Surgical Based)* 1
Secretariat State Quality Officer 1
Surgeons (every Surgical-based discipline) 1
Anaesthesiologist 1
State Infectious Diseases Physician (if available) 1
State Infection Control Representative 1
Member
State Wound Care Committee Representative 1
State Nursing Representative 1
State Assistant Medical Officer Representative 1
Hospital’s SSI Secretariat (each hospital) 1
*appointed by the State Health Director

The State Quality Officer’s tasks are:

i) as the Secretariat for State SSI Committee.
ii) to monitor, compile & analyse the data from the hospitals under their purview on a
monthly basis.
iii) to coordinate State SSI Committee meetings biannually.
iv) to present the analysis of SSI data including identified issues as well as
recommendations from the State SSI committee during the State Infection &
Antibiotics Control Committee (SIACC) meeting.
v) to give feedback of the analysis to the hospitals involved and to the SSI National
Secretariat i.e. the Clinical Audit Unit.

53
NATIONAL
At the National level, the National SSI Committee meets biannually. The National SSI
Committee members:
i) must agree to the Terms of Reference (TOR).
ii) are expected to review SSI cases and make recommendations for improvement.
iii) are expected to prepare case summaries to be published in the bulletin or report.
iv) are expected to prepare annual National SSI Surveillance Report.
v) are expected to assist the Hospital and State Committee to ensure the smooth
process of surveillance and reporting.
vi) are expected to aid in education, training and awareness of SSI programme at the
hospital, state or national level.
vii) are expected to participate and contribute in SSI programme activities such as
Conference, Workshop, Audit and Roadshow.

Table 5
National SSI Committee
Position Committee Members
Advisor 1 Deputy Director General of Health (Medical)
Advisor 2 Director of Medical Development Division
Chairperson Senior Consultant Surgeon (Surgical Based)
Deputy Chairperson Senior Consultant Surgeon (Surgical Based)
Deputy Director, Medical Care Quality Section
Secretariat
Clinical Audit Unit, Medical Care Quality Section
Senior Consultant Surgeons
Senior Consultant Anaesthesiologist
Senior Consultant Internal Medicine Physician (Infectious Disease)
Member Representative from Infection Prevention and Control Unit, MOH
Representative from Surgical Services Unit, MOH
Representative from Ministry of Defence
Representative from Ministry of Higher Education

Summary of the findings and recommendations must be presented at the Jawatankuasa

Kawalan Infeksi dan Antibiotik Kebangsaan (JKKIAK) twice a year by the National Secretariat,
i.e. Clinical Audit Unit or the committee member. The Secretariat shall provide feedback to
all the stakeholders based on the findings and recommendations.

The flow of the reporting mechanism and surveillance is as followed:

54
SSI Reporting Flow Chart

55
Reference

1) Berríos-Torres, S. I. et. el. (2017). Centers for Disease Control and Prevention
Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surgery, 152(8),
784. doi.org/10.1001/jamasurg.2017.0904
2) Centers for Disease Control and Prevention. (2023). Surgical Site Infection Event
(SSI). National Healthcare Safety Network (NHSN).
https://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf
3) Malaysia One Health Antimicrobial Resistance. (2022, November 29). Point
Prevalence Survey (PPS) On Healthcare Associated Infection & Antibiotics -
Malaysia One Health Antimicrobial Resistance. Malaysia One Health Antimicrobial
Resistance -. https://myohar.moh.gov.my/point-prevalence-survey-pps-on-
healthcare-associated-infection-antibiotics/

56
PART 4 - WOUND MANAGEMENT
WOUND MANAGEMENT

Please refer to Wound Care Manual, Second Edition 2023, Ministry of Health, Malaysia

57
APPENDIX
APPENDIX 1
 Withholding Anticoagulant Tables

Table 1: Withholding warfarin pre-procedure for patients not requiring bridging therapy.

6 days 5 days 4 days 3 days 2 days 1 days

Morning of
prior to prior to prior to prior to prior to prior to
surgery
surgery surgery surgery surgery surgery surgery
Take last
No No No No No No
Warfarin dose of
warfarin warfarin warfarin warfarin warfarin warfarin
warfarin
INR Test X X X X X Check if INR <1.5

Table 2: Withholding warfarin and commencing enoxaparin pre-procedure for patients requiring
bridging therapy.

6 days 5 days 4 days 3 days 2 days 1 days Morning

prior to prior to prior to prior to prior to prior to of
surgery surgery surgery surgery surgery surgery surgery
Take last
No No No No No No
Warfarin dose of
warfarin warfarin warfarin warfarin warfarin warfarin
warfarin
Either 1 day prior or
INR Test X X Check INR morning of surgery,
Check if INR <1.5
Cease enoxaparin 24
No No Commence enoxaparin when INR
Enoxaparin hours before
enoxaparin enoxaparin is ≤ 2
procedure

Table 3: Withholding novel anticoagulants in patients with normal renal profile

Type of Anticoagulants with When to cease anticoagulant in When to cease anticoagulant in

dose Low bleeding Risk Surgery High Bleeding Risk Surgery
Dabigatran (Pradaxa) Last dose 24 hours before Last dose 48 hours before
110 mg or 150 mg twice a day surgery surgery
Apixaban (Eliquis) Last dose 24 hours before Last dose 48-72 hours before
2.5 mg or 5 ml twice a day surgery surgery
Rivoroxaban (Xaretto) Last dose 24 hours before Last dose 48-72 hours before
15 mg or 20 mg once a day surgery surgery

Table 4: Withholding antiplatelet therapy prior to surgery (if required).

Type of Antiplatelet agents When to cease antiplatelet therapy (if required)

Aspirin At least 5 days prior
Clopidogrel At least 7 days prior
Prasugrel At least 7 days prior
Ticagrelor At least 5 days prior
Ticlopidine At least 14 days prior
APPENDIX 2
 Surgical Site Infection (SSI) Data Collection Form*
Hospital: Department:

Patient Detail
Name
Race Male Female
Age: Date of Birth (dd/mm/yyyy): ID No./ Passport: MRN No.:

Contact No.

Date of surgery
Date of readmission
Surgery start time Surgery end time
Duration of surgery
Surgery performed
Type of surgery Clean Clean contaminated Contaminated
Primary surgeon Specialist >5 Years Specialist <5 Years Medical Officer

PRE-OPERATIVE
Diagnosis
Date of Admission:
Body Mass Index (BMI)
Antibiotic Prophylaxis: Yes No Diabetes Mellitus: Yes No Unknown
Bathing: Yes No Hair Removal: Shaving Clipping Not Done
Smoking/ Vaping: Non Active Ex (≥ 4 Weeks)
Immunosuppresant Steroids Chemotherapy Biologic
Therapy Radiotherapy None

INTRA-OPERATIVE
Skin Preparation Alcohol Base Aqueous Base
Povidone Chlorhexidine
Unknown
Antibiotic Prophylaxis Yes No Time of Administration (1st Dose):
Redosing 2nd Dose 3rd Dose
Redosing Reason Bleeding Prolonged Surgery
Others:
Drain Yes No

POST-OPERATIVE
Uncontrolled Sugar (>11.1 mm/l) Yes No
Duration of Antibiotic Within 24 Hours
≥ 24 Hours
Duration of Antibiotic ≥ 48 Hours
(Only Cardiac & Vascular Surgery)
≤ 48 Hours

TYPE OF SSI
Day of SSI Identified – Post-op
Site of SSI
Diagnosis Clinical Lab Confirmed
If Lab Confirmed – Type of Organism

*Link for the form:

1. MPIS System
• www.cprchospital.moh.gov.my
2. Google Form
• https://docs.google.com/forms/d/e/1FAIpQLSfFPbsbZnS7NCIFOGAjBLBJYhK
Thd3vLnZ8dqldIRsT47ueFw/viewform
APPENDIX 3A
 SSI SURVEILLANCE DISCHARGE LEAFLET

If you experience any of these following symptoms, please go to nearest

Emergency Department or Health Clinic/ Clinic.*

Hospital

Patient’s Name

Discharge Ward

Name of Surgery

Diagnosis

Signs and Symptoms

• Pain Yes No
• Swelling Yes No

• Discharge Yes No

• Fever Yes No

• Wound Gap / Open Wound Yes No

* For attending doctors (from Emergency Department/ Health Clinic/ Private

Clinic), in case an SSI is detected, kindly refer this patient back to us or
contact us at this number: ______________________________.

Attending Doctor,

…………………………………………………….
( )
*Official stamp and date.

SSI CAU MOH 2023

APPENDIX 3B
 RISALAH DISCAJ SURVELAN SSI

Jika anda mengalami mana-mana gejala berikut, sila pergi ke Jabatan

Kecemasan atau Klinik (KK/ Swasta) yang terdekat*.

Hospital

Nama Pesakit

Wad

Nama Pembedahan

Diagnosis

Tanda dan gejala

• Rasa sakit Ya Tidak
• Bengkak Ya Tidak

• Lelehan/ Berair/ Nanah Ya Tidak

• Demam Ya Tidak

• Jurang Luka/ Luka Terbuka Ya Tidak

* Bagi doktor di Jabatan Kecemasan/ Klinik Kesihatan/ Klinik Swasta,

sekiranya SSI dikesan, sila rujuk pesakit ini kembali kepada kami atau
hubungi kami di nombor ini: ______________________________.

Yang benar,

.............................................................
( )
*Cop rasmi dan tarikh.

SSI CAU MOH 2023

APPENDIX 4
No. Surgery Definition Reference
1 Colectomy Surgical procedure to remove part or all of colon. myclevelandclinic.org
Surgical procedure to remove part or all of colon and
2 Proctocolectomy myclevelandclinic.org
rectum.
Mastectomy +/- Axillary Removal all breast tissue, including the overlying skin, the
3 www.facs.org
Clearance nipple, areola, and at least 6 axillary lymph nodes at level 2.
Surgical procedure performed to transfix the hernia sac and
4 Hernioplasty reinforcement of the weakened or damaged abdominal myclevelandclinic.org
wall using a mesh.
Surgical removal of all (total thyroidectomy) or part (partial
5 Thyroidectomy myclevelandclinic.org
thyroidectomy) of the thyroid gland.
6 Cholecystectomy A surgery to remove the gallbladder. myclevelandclinic.org
Seidlitz C, Kip M. Introduction to the Indications and
The surgical replacement of a joint with artificially produced Procedures. In: Bleß HH, Kip M, editors. White Paper on Joint

E
IN
EL
ID
I GU
SS
T
AF
DR
material. Total arthroplasty refers to the replacement of all Replacement: Status of Hip and Knee Arthroplasty Care in
7 Arthroplasty joint surfaces concerned, while partial replacement involves Germany [Internet]. Berlin (Germany): Springer; 2018.
the replacement of only one or some of the surfaces but Chapter 1. Available from:
not the entire joint. https://www.ncbi.nlm.nih.gov/books/NBK546138/ doi:
10.1007/978-3-662-55918-5_1
A craniotomy is the surgical removal of part of the bone
from the skull to expose the brain. Specialized tools are
used to remove the section of bone called the bone flap. https://www.hopkinsmedicine.org/health/treatment-tests-
8 Craniotomy
The bone flap is temporarily removed, then replaced after and-therapies/craniotomy
the brain surgery has been done
 This involves taking out the diseased segment of colon in
case of Hirschsprung’s disease and anorectal anomaly.
Then the rest of the colon is pulled down and connected to
the anus. Sometimes, the surgeon can do this surgery using
9 Pull-through Procedure https://www.cincinnatichildrens.org/health/h/hirschsprung
minimally invasive laparoscopic or robot-assisted surgery.
This can mean less pain, less blood loss, smaller scars with
faster healing and shorter hospital stays, compared to what
patients may have with an “open” or traditional surgery
Involves the insertion of a flexible and sterile thin plastic
tube, or catheter, into a blood vessel to provide an effective
Vascular Access Surgery (VAS) -
10 method of drawing blood or delivering medications, blood radiologyinfo.org
(paediatric)
products, or nutrition into a patient's bloodstream over a
period of weeks, months or even years.
Complex surgical procedure in which a surgeon removes
11 Cystectomy myclevelandclinic.org
some or all the urinary bladder

E
IN
EL
ID
I GU
SS
T
AF
DR
Surgery to remove a kidney. Bilateral nephrectomy is
removal of both kidneys. A partial nephrectomy is to
12 Nephrectomy myclevelandclinic.org
remove only a portion of the kidney. A radical nephrectomy
is removal of the entire kidney and surrounding tissue.
An abdominal incision is made to gain access to abdominal
aorta; to identify the aneurysm. The aneurysm is opened
13 Open AAA Repair myclevelandclinic.org
and the graft is sewn onto it. The graft reinforces the
aneurysm to prevent a rupture.
Renal Access Surgery/ AVF Skin incision made to identify and anastomose vein and
14 radiologyinfo.org
(vascular adult) artery for creation of renal venous access.
 Surgery to create a new way (bypass) for blood to reach the
Coronary Artery Bypass Graft heart without going through the blocked artery. A blood
15 myclevelandclinic.org
Surgery vessel is taken from some other parts of the body e.g., arm,
leg or chest to create the bypass
Surgery to replace the aortic valve; either a biological valve
16 Aortic Valve Replacement Surgery myclevelandclinic.org
(from human or animal tissue) or a mechanical valve.
https://www.hopkinsmedicine.org/health/treatment-tests-
17 Lung Lobectomy A surgery to remove one of the lobes of the lungs
and-therapies/lobectomy
Surgery used to correct abnormal development a special
Cleft Lip Repair and Cleft Palate
18 technique to suture the two sides of the lip together, Garb & Smith’s Plastic Surgery
Repair
leaving a scar which blends into the lip
19 Flap Donor Site Site of tissue where flap has been harvested Garb & Smith’s Plastic Surgery
Full Thickness Skin Graft Donor
20 Skin graft that contains entire dermis Garb & Smith’s Plastic Surgery
Site
A total hysterectomy is the surgical removal of the uterus

E
IN
EL
ID
I GU
SS
T
AF
DR
21 Total Abdominal Hysterectomy and cervix. In an abdominal hysterectomy, the uterus is The Royal College of Obstetricians and Gynaecologists
removed through an incision in the abdomen
22 Bilateral Salpingo-Oophorectomy Both the ovaries and the fallopian tubes are removed myclevelandclinic.org
Lower Segment Caesarean The delivery of a baby through a surgical incision in the https://www.hopkinsmedicine.org/health/treatment-tests-
23
Sections (LSCS) abdomen and lower and-therapies/cesarean-section
El Sayed Ahmad Y, Winters R. Parotidectomy. [Updated 2023
Jan 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls
24 Parotidectomy Partial or complete removal of the parotid gland
Publishing; 2023 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK557651/
Submandibulectomy/ Surgical procedure to remove one or both salivary glands https://www.hopkinsmedicine.org/health/treatment-tests-
25
Submandibular Gland Excision under the jaw (mandible). and-therapies/submandibular-gland-excision
 A surgical procedure in which the fibro-fatty soft tissue Harish K. Neck dissections: radical to conservative. World J
26 Neck Dissection content of the neck is excised to remove the lymph nodes Surg Oncol. 2005 Apr 18;3(1):21. doi: 10.1186/1477-7819-3-
that are contained therein 21. PMID: 15836786; PMCID: PMC1097761.
Kartini D, Panigoro SS, Harahap AS. Sistrunk Procedure on
Excision of thyroglossal duct cyst, the middle part of hyoid
Sistrunk Surgery (Excision of Malignant Thyroglossal Duct Cyst. Case Rep Oncol Med.
27 bone and the surrounding tissue around the thyroglossal
Thyroglossal Cyst) 2020 Jan 16;2020:6985746. doi: 10.1155/2020/6985746.
tract.
PMID: 32395358; PMCID: PMC7201451.
Houck J. Excision of branchial cyst. Operative Techniques in
Otolaryngology Head and Neck Surgery. Updated
28 Excision of Branchial Cyst Complete surgical removal of branchial cyst
September 2005.
doi:http://doi.org/10.1016/j.otot.2005.09.007
Cochlear implants. NIDCD Fact Sheet. National Institute on
Surgical implantation of a small, complex electronic device
Deafness and Other Communicable Disorders. NIH
29 Cochlear Implant Surgery that can help to provide a sense of sound to a person who
Publication No. 00-4798. February 2016. Last updated March
is profoundly deaf or severely hard-of-hearing
2021.

E
IN
EL
ID
I GU
SS
T
AF
DR
Joo, D., Kim, P.D. (2013). Total Laryngectomy and
Surgical procedure in which the entire larynx is removed
Laryngopharyngectomy. In: Kountakis, S.E. (eds)
from hyoid bone superiorly to the cricoid cartilage and
30 Laryngectomy Encyclopedia of Otolaryngology, Head and Neck Surgery.
often extending down to the tracheal rings inferiorly for the
Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-
purpose of resecting advanced laryngeal cancer.
642-23499-6_123
Partial removal of a surgically incurable malignant
neoplasm without curative intent to make subsequent Silberman AW. Surgical debulking of tumors. Surg Gynecol
31 Tumour Debulking
therapy with drugs, radiation or other adjunctive measures Obstet. 1982 Oct;155(4):577-85. PMID: 6750827
more effective and, thereby, improve the length of survival.
Simple surgical procedures that involve the hard and soft
32 Minor Oral Surgery tissues of the oral cavity which may or may not be related www.harlestonedental.co.uk
to dental problems
 Elective Oral & Maxillofacial A planned, non-emergency surgical management of facial
33 www.harlestonedental.co.uk
Trauma Surgery bone fractures
Removal of an opaque or cloudy natural crystalline lens and https://www.nei.nih.gov/cataract/cataract-surgery
34 Cataract Surgery
usually is replaced by an artificial lens

E
IN
EL
ID
I GU
SS
T
AF
DR
 CLINICAL AUDIT UNIT
MEDICAL CARE QUALITY SECTION
MEDICAL DEVELOPEMENT DIVISION
MINISTRY OF HEATH MALAYSIA