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Surgical Draping & Skin Antisepsis

Plan the prepared field around the actual incisions, mucosal access and positioning.

Select the Preparation by Site and Product​

Site or situationPractical approach
Intact abdominal skinUse an alcohol-based antiseptic unless contraindicated (CDC 2017). WHO's own Recommendation 12 is a strong recommendation, low-to-moderate quality evidence, for an alcohol-based chlorhexidine gluconate solution; an iodophor–alcohol preparation is a trial-supported alternative from later trials, not from the WHO recommendation itself. Check the exact product, allergy history and procedure.[1][2][3][11]
External genital or perineal skinAccount for adjacent urethral and vaginal mucosa, folds and pooling. ACOG gives a 2-minute chlorhexidine–alcohol scrub for moist sites such as the vulva and inguinal fold (30 seconds for dry abdominal skin), then 3 minutes to dry.[3] Do not transfer an abdominal-skin protocol to every genital site. Product labeling differs even between chlorhexidine preparations: the 26-mL ChloraPrep applicator is not for open skin wounds and is labeled for an area from 8.4 × 8.4 in to approximately 13.2 × 13.2 in per applicator, and the 4% aqueous CHG label excludes the genital area and warns against contact with eyes, ears and mouth.[3][7][8]
Premature infants or infants under 2 monthsChlorhexidine preparations, including aqueous formulations, can cause chemical injury in preterm infants. Both cited chlorhexidine labels direct use with care in this age group because irritation or chemical burns may occur; select the site, formulation and amount under the pediatric team’s protocol.[2][7][8]
VaginaUse a preparation suitable for vaginal antisepsis under the institutional protocol. ACOG Practice Bulletin 195 recommends cleansing with either povidone-iodine or 4% chlorhexidine gluconate before hysterectomy or vaginal surgery (Level C). ACOG's 2018 bulletin described povidone-iodine as the only FDA-approved vaginal antiseptic; AORN's 2025 guidance identifies 3% chloroxylenol as another FDA-approved option when povidone-iodine is contraindicated.[3][16] Vaginal 4% chlorhexidine gluconate soap containing about 4% isopropyl alcohol is an off-label option for povidone-iodine allergy or surgeon preference. Do not use the usual 70% isopropyl-alcohol skin preparations intravaginally.[3]
Known antiseptic allergy or another contraindicationIdentify the ingredient and prior reaction, then choose a site-appropriate alternative. For suspected chlorhexidine allergy, check planned dressings, coated catheters or lines, and any chlorhexidine-containing urethral lubricant used during catheterization; these exposures can trigger perioperative anaphylaxis. Formulations with the same antiseptic name are not interchangeable.[2][7][8][14][15]

Chlorhexidine and alcohol percentages describe separate ingredients. ACOG describes a commonly used 4% chlorhexidine soap containing 4% alcohol; that description does not establish the composition or genital suitability of other 4% chlorhexidine products.[3][8] For example, the cited 4% Micro-Guard CHG label specifically excludes the genital area.[8]

What the Higher-Level Evidence Establishes​

Alcohol-containing skin antiseptics: earlier comparisons favoring chlorhexidine–alcohol over aqueous povidone-iodine do not isolate the effect of chlorhexidine from that of alcohol. The following large trials clarify comparisons between alcohol-containing preparations:[3]

StudyMain resultLimit of application
PICASSO, JAMA 2024In a cluster-randomized crossover trial of elective cardiac or abdominal surgery, 3,321 patients were analyzed (pregnant patients and emergency operations were excluded). The primary SSI endpoint pooled 30-day abdominal outcomes with 1-year cardiac outcomes (shortened to 90 days for cardiac patients in 16 of 52 cluster periods during COVID-19); SSI occurred in 80/1,570 (5.1%) with povidone-iodine in alcohol and 97/1,751 (5.5%) with chlorhexidine in alcohol. Povidone-iodine met the prespecified 2.5-percentage-point noninferiority margin.[4]Supports the tested alternative in those settings, not universal equivalence; the abdominal subgroup (6.8% vs 9.9%, RR 0.69, 95% CI 0.46–1.02) was underpowered, and mucosal use was outside the trial.
PREPARE, NEJM 2024In closed-fracture surgery, the prespecified SSI outcome included superficial infection within 30 days and deep incisional or organ-space infection within 90 days; it occurred in 2.4% with iodine povacrylex–alcohol versus 3.3% with chlorhexidine–alcohol (OR 0.74, 95% CI 0.55–1.00). The open-fracture comparison did not show a clear difference.[5]Iodine povacrylex is not povidone-iodine.

A 2025 meta-analysis of 10 randomized trials in abdominal surgery likewise found no significant difference between chlorhexidine–alcohol and iodine–alcohol (RR 1.20, 95% CI 0.94–1.54).[12]

Vaginal preparation: a 2025 hysterectomy systematic review included 10 studies and 9,618 patients, but only four small randomized trials (306 participants); the rest were nonrandomized comparisons. Chlorhexidine was associated with fewer positive vaginal cultures, while the pooled SSI estimate did not show a clear reduction versus povidone-iodine (OR 1.22, 95% CI 0.91–1.63). Adverse-event reporting was limited. The review's culture result is a surrogate; SSI and adverse-event data are insufficient for formulation-specific conclusions.[6]

Drying, Hair and Fire Prevention​

Follow the specific applicator's instructions for application, contact time, treated area and drying. Prevent pooling in skin folds, beneath the patient or near tourniquets; remove soaked materials before draping or using an ignition source.[2][7]

The cited 26-mL ChloraPrep label requires complete drying before draping, with at least three minutes on hairless skin and potentially up to one hour in hair. Do not blot an alcohol preparation dry to shorten the prescribed process.[7]

Avoid routine hair removal. When hair interferes with surgery, WHO recommends clipping and discourages shaving; ACOG advises removing it immediately before the operation, preferably with electric clippers and not a razor (Level C).[1][3] The 2023 SHEA/IDSA/APIC guidance says razors may be acceptable for selected male genital procedures, citing a small scrotal trial with less skin trauma from razors and no observed SSI advantage from clippers; the method remains procedure-specific and should avoid skin injury.[1][17]

Sterile Drapes and Adhesive Incise Drapes​

Sterile surgical drapes remain part of the operative barrier. WHO permits either suitable sterile reusable woven or disposable non-woven systems; available SSI evidence has not established a clear winner. Material integrity, fluid resistance, validated processing, waste and cost remain relevant.[1] The 2026 AUGS sustainability white paper likewise found no definitive evidence that disposable drapes and gowns lower surgical site infection, and lists reusable drapes and gowns among suggested measures where reprocessing is readily available (most life cycle analyses it reviewed favored reusable items).[13]

Adhesive incise drapes are a separate issue:

  • Cochrane found higher SSI risk with plain adhesive drapes than with no adhesive incise drape (five trials, 3,082 participants; RR 1.23, 95% CI 1.02–1.48). Two trials of iodophor-impregnated drapes showed no clear benefit (1,113 participants; RR 1.03, 95% CI 0.66–1.60). These were older, varied procedures and products.[9]
  • WHO conditionally advises against using adhesive incise drapes, with or without antimicrobial impregnation, for SSI prevention. NICE advises avoiding routine plain incise drapes and using an iodophor-impregnated product if an incise drape is required, unless contraindicated by allergy.[1][2]

GU Setup and the Wider Infection-Prevention Plan​

Coordinate abdominal, perineal, vaginal and oral donor-site access when those fields are actually needed. For a combined vaginal and abdominal preparation, AORN’s 2025 operative guidance places the vaginal prep first, followed by a separate abdominal setup, hand hygiene and fresh sterile gloves; field separation and instrument changes follow contamination risk. Before urethral catheterization after vaginal preparation, the prep gloves are removed, hand hygiene is performed and fresh sterile gloves are donned.[16] Positioning and safeguards against sliding, including lithotomy, Trendelenburg angle and chest-strap use, follow the planned operation and positioning guidance.

In a single-center before-and-after series of cystectomy, nephrectomy and prostatectomy, superficial SSI was 22/615 (3.57%) before the OR bundle and 7/510 (1.37%) in the later interval with both the bundle and alcohol-based skin preparation. The design cannot determine which component caused the change or prove that every bundle outperforms every individual intervention.[10] Use the companion pages for antimicrobial prophylaxis, prosthetic infection prevention, hand antisepsis and gloving.

References​

1. World Health Organization. Global Guidelines for the Prevention of Surgical Site Infection. 2nd ed. 2018. Sections 4.6, 4.7 and 4.16. Guideline.

2. NICE. Surgical site infections: prevention and treatment. NG125. Recommendations 1.3.1–1.3.10, including antiseptic selection and incise drapes. Recommendations.

3. ACOG. Prevention of infection after gynecologic procedures. Practice Bulletin No. 195. Obstet Gynecol. 2018;131:e172–e189. doi:10.1097/AOG.0000000000002670.

4. Widmer AF, Atkinson A, Kuster SP, et al. Povidone iodine vs chlorhexidine gluconate in alcohol for preoperative skin antisepsis: a randomized clinical trial. JAMA. 2024;332(7):541–549. doi:10.1001/jama.2024.8531.

5. Sprague S, Slobogean G, Wells JL, et al; PREP-IT Investigators. Skin antisepsis before surgical fixation of extremity fractures. N Engl J Med. 2024;390:409–420. doi:10.1056/NEJMoa2307679.

6. Rozycki SK, Nguyen V, Miroballi N, et al. Vaginal antiseptic preparation at the time of hysterectomy: a systematic review and meta-analysis. Am J Obstet Gynecol. 2025;232(5):422–431.e4. doi:10.1016/j.ajog.2024.12.031.

7. DailyMed. ChloraPrep 26-mL applicator: chlorhexidine gluconate 2% and isopropyl alcohol 70%. Product-specific labeling. Label.

8. DailyMed. Coloplast Micro-Guard CHG Solution, chlorhexidine gluconate 4% solution. Updated March 27, 2026. Product-specific genital-area restriction. Label.

9. Webster J, Alghamdi A. Use of plastic adhesive drapes during surgery for preventing surgical site infection. Cochrane Database Syst Rev. 2015;(4):CD006353. doi:10.1002/14651858.CD006353.pub4.

10. Vij SC, Kartha G, Krishnamurthi V, et al. Simple operating room bundle reduces superficial surgical site infections after major urologic surgery. Urology. 2018;112:66–68. doi:10.1016/j.urology.2017.10.028.

11. Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg. 2017;152(8):784–791. doi:10.1001/jamasurg.2017.0904

12. Hsieh HH, Yu Y, Chang CJ, et al. A comparative meta-analysis of povidone-iodine-alcohol vs. chlorhexidine-alcohol for preoperative skin antisepsis in abdominal surgery. Am J Surg. 2025;244:116318. doi:10.1016/j.amjsurg.2025.116318

13. Chen CCG, Andiman S, Long J, et al. Health Care Sustainability: Strategies for Operating Rooms and Urogynecologic Procedures. Urogynecology (Phila). 2026;32(6):569-577. doi:10.1097/SPV.0000000000001835

14. Medicines and Healthcare products Regulatory Agency. "All medical devices and medicinal products containing chlorhexidine: risk of anaphylactic reaction due to chlorhexidine allergy." Medical Device Alert MDA/2012/075. Issued October 25, 2012. MHRA alert.

15. Totty J, Forsyth J, Mekako A, Chetter I. "Life-threatening intraoperative anaphylaxis as a result of chlorhexidine present in Instillagel." BMJ Case Rep. 2017;2017:bcr2017221443. doi:10.1136/bcr-2017-221443.

16. Association of periOperative Registered Nurses. "Vaginal Prep for Surgery." AORN. February 8, 2025. Operative guidance.

17. Calderwood MS, Anderson DJ, Bratzler DW, et al. "Strategies to prevent surgical site infections in acute-care hospitals: 2022 Update." Infect Control Hosp Epidemiol. 2023;44(5):695–720. doi:10.1017/ice.2023.67