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Which of the following components of an infection prevention bundle has the most significant impact in reducing surgical site infections in elective colorectal surgery patients? A. Preoperative shower with 4% chlorhexidine gluconate B. Mechanical bowel preparation C. Intraoperative abdominal irrigation with antibiotic D. Mechanical bowel preparation combined with oral antibiotics E. Dedicated instruments for wound closure ANSWER: D Surgical site infections (SSIs) after colorectal surgery are a significant cause of morbidity and mortality and remain an important national quality indicator. Mechanical bowel preparation plus oral antibiotics was a mainstay in colorectal surgery for decades, but several publications questioned the efficacy of mechanical bowel preparation. Numerous randomized controlled trials failed to show any decrease in SSIs or anastomotic leak. A major criticism of these trials was omission of the oral antibiotic portion of the standard bowel preparation. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) retrospectively evaluated 4999 patients who underwent colectomy. Patients who had a combined mechanical bowel preparation and oral antibiotics had a lower 30-day rate of superficial SSIs, anastomotic leak, and 30-day readmission, compared with mechanical bowel preparation alone. Infection prevention bundles are used to reduce the rates of infection related to central line insertions and mechanical ventilation. Several interventions in the preoperative and perioperative arenas are proposed to reduce the rates of SSI in colorectal patients, and institutions have grouped them together in an infection prevention bundle. One group studied the impact of each component of the infection prevention bundles: mechanical bowel preparation plus oral antibiotics, preoperative chlorhexidine shower, preoperative hair clipping, skin preparation with a standard chlorhexidine alcohol solution, intraoperative antibiotic irrigation, and a clean closure protocol with dedicated instruments. Multivariate analysis showed that the mechanical bowel preparation with oral antibiotics had the greatest effect on reducing SSIs.