CDC Updates Surgical Site Infection Guidelines
Clinical Context
During the past several decades, there has been an increased focus on healthcare-associated infections and their prevention, and a review by Umscheid and colleagues[1] summarized the negative consequences of these infections and just how preventable they might be. They found that 65% to 70% of cases of catheter-associated bloodstream infections (CABSIs) and catheter-associated urinary tract infections (CAUTIs) may be preventable, as may 55% of cases of ventilator-associated pneumonia and surgical site infections (SSIs).
CAUTI was estimated to be the most preventable healthcare-associated infection, but CABSI was associated with the most healthcare costs and highest risk for mortality. SSIs were less likely to cause mortality, but they remain an important cause of healthcare-associated infection. Recommendations from the US Centers for Disease Control and Prevention (CDC) described below represent an evidence-based approach to the prevention of SSIs.
Synopsis and Perspective
The CDC has issued updated evidence-based recommendations for preventing SSIs. The guidelines cover 14 core areas and are intended for incorporation into existing surgical quality improvement programs for greater patient safety.
The 2017 recommendations, published online May 3 in JAMA Surgery,[2] supersede the CDC's 1999 SSI guidelines,[3] which were published before the routine use of evidence-based grading.
After an initial systematic literature review of more than 5000 items published between 1998 and 2014, the CDC's Healthcare Infection Control Practices Advisory Committee settled on 170 eligible studies for analysis. Using a modified version of the standard GRADE approach (Grading of Recommendations, Assessment, Development, and Evaluation), the panel assessed evidence quality and balance of benefits and harms, assigned a strength level for each recommendation, ranging from 1A (strong recommendation with evidence of high to moderate quality) to no recommendation/unresolved issue. Of 42 statements, 25 ended up with no recommendation/unresolved status.
Among the updated recommendations:
Advise patients to have a full-body shower or bath with soap (antimicrobial only as needed) or an antiseptic agent no earlier than the night before the day of surgery.
Before cesarean delivery, administer antimicrobial prophylaxis before incision.
In most cases, use an alcohol-based agent for skin preparation in the operating room.
It is not necessary to use plastic adhesive drapes with or without antimicrobial properties to prevent SSIs.
For clean and clean-contaminated procedures, do not give additional prophylactic antimicrobial doses after closing the surgical incision, even if the patient has a drain in place.
Do not apply topical antimicrobial agents to the incision.
Maintain intraoperative glycemic control in diabetic and nondiabetic patients, targeting blood glucose levels of less than 200 mg/dL.
Maintain patient normothermia.
In patients with normal lung function undergoing general anesthesia with endotracheal intubation, administer a higher fraction of inspired oxygen (FIO2) during surgery and after extubation in the immediate postoperative period.
Do not withhold transfused blood products as a means to prevent SSIs.
"These guidelines were developed in close partnership with the specialty surgical societies, and their designated [guideline] coauthors, who help to ensure that recommendations meet the needs of the field," coauthor Erin C. Stone, MA, a CDC public health analyst, told Medscape Medical News. "As with any guideline, implementation will require consideration of local systems, something quality improvement committees and officers routinely do."
Led by Sandra I. Berrios-Torres, MD, from the CDC's Division of Healthcare Quality Promotion in Atlanta, Georgia, the guideline authors stress that prevention of SSIs is ever more important as the number of US surgical procedures rises and reimbursements for SSIs are being reduced or denied.[4]
Between 2006 and 2009, primary site infections complicated approximately 1.9% of surgeries in the United States, the authors note, and the true number is likely higher, as approximately half of SSIs manifest after discharge, the authors note.
The authors add that although the 1999 guideline was "evidence informed," most of its recommendations were based on expert opinion, as evidence-based guideline methods were not the norm at the time. They anticipate the 2017 recommendations will serve both healthcare practitioners wanting more precise guidance on implementation and organizations seeking to set research priorities.
They concede that the dearth of robust evidence across many guideline categories left substantial gaps and "created challenges in formulating recommendations for the prevention of SSIs. Nonetheless, the thoroughness and transparency achieved using a systematic review and the GRADE approach to address clinical questions of interest to stakeholders are critical to the validity of the clinical recommendations," they write.
The guideline's many unresolved issues highlight the need for further research and may help prioritize a research agenda in this critical field, according to the authors. "Adequately powered, well-designed studies that assess the effect of specific interventions on the incidence of SSI are needed to address these evidence gaps," they write.
In an invited commentary,[5] Pamela A. Lipsett, MD, MHPE, MCCM, from the Department of Surgery, Anesthesiology, and Critical Care Medicine at the Johns Hopkins University School of Medicine, Baltimore, Maryland, and section editor of JAMA Surgery, commended the "long-awaited update" as useful for telling surgeons "what we should do and what we do not know."
However, she also notes that a large number of statements are left unresolved. "Unfortunately, in many cases the authors make no recommendation with respect to support or harm if the level of the evidence was low or very low or if they were unable to judge trade-offs between harms and benefits of the proposed intervention because of lack of outcomes."
Dr Lipsett also singled out a well-supported recommendation that might prove problematic. This relates to limiting antimicrobial prophylaxis procedures to use during actual surgery, even when a drain is present. "These recommendations are likely to be the most difficult to operationalize because some surgeons and practices have had difficulty confining antibiotic use to just 24 hours after a clean or clean-contaminated procedure, let alone when a drain is in place," she writes.
Also potentially problematic is the recommendation for the administration of a higher FIO2 during and after surgery to intubated patients. "This recommendation is based on moderate evidence and is controversial regarding lack of potential efficacy and potential harms,' Dr Lipsett writes.
However, such gaps serve to point the way forward. "The fact that most statements were unresolved, especially regarding prosthetic joint surgery, shows our investigators where we should be putting forth our efforts in clinical trials," Dr Lipsett concludes. "There is a lot of opportunity to learn how we can provide more effective care to our patients."
The guideline was produced with the support and developmental involvement of the CDC. Several members of the guideline panel have disclosed relevant financial relationships with the private sector outside the scope of this guideline. The editorial commentator has disclosed no relevant financial relationships.
JAMA Surg. Published online May 3, 2017.
Guideline Highlights
Researchers performed a targeted review of studies published between 1998 and 2014. 5487 relevant articles were found on the initial search, and 896 underwent full-text review. 170 results were ultimately considered in the generation of the recommendations.
Researchers excluded studies of "dirty" surgical procedures, studies focused only on dental procedures, and studies of procedures that did not feature primary closure in the operating room.
Patients should bathe or shower with nonantimicrobial soap, antimicrobial soap, or an antiseptic agent at least the night before surgery.
An alcohol-based antiseptic agent should be used to cleanse the skin just before surgery.
However, microbial sealants and plastic adhesive drapes with antimicrobial properties are unnecessary in the prevention of infection.
Intraoperative irrigation of deep or subcutaneous tissues with aqueous iodophor solution should be considered, but intraperitoneal lavage in contaminated or dirty bowel procedures is unnecessary.
Insufficient evidence exists to recommend soaking of prosthetic devices in antiseptic solutions before surgery.
Preoperative antimicrobial agents should be offered only according to established guidelines, and these drugs should be administered to maximize serum concentrations at the time of incision.
Women should receive antimicrobial prophylaxis before cesarean delivery.
Insufficient evidence exists to recommend adjusting the dose of antimicrobial therapy based on the body weight of the patient. The benefits of adding further doses of antimicrobials during surgery are also largely unproven.
In clean and clean-contaminated procedures, postsurgical prophylactic antibiotics are unnecessary, even when a drain is in place.
Topical antimicrobial agents to the wound site are discouraged, and the value of antimicrobial dressings is unclear. However, triclosan-coated sutures may be used to help prevent SSIs.
Serum glucose levels should be maintained at less than 200 mg/dL in the perioperative period. Increased FIO2 is recommended during surgery among patients receiving endotracheal intubation, but the optimal FIO2 target or duration of treatment is not clear.
The transfusion of blood products should not be withheld from patients to prevent SSIs.
Clinical Implications
Patients should bathe or shower with nonantimicrobial soap, antimicrobial soap, or an antiseptic agent at least the night before surgery in order to prevent SSIs. However, microbial sealants and plastic adhesive drapes with antimicrobial properties are unnecessary in the prevention of SSIs, and preoperative antimicrobials should be dosed to maximize serum concentrations at the time of incision.
The benefits of repeated dosing of antimicrobial agents during surgery to prevent SSIs are largely unknown. Topical antimicrobial agents to the wound site are discouraged, and the value of antimicrobial dressings is unclear. Serum glucose levels should be maintained at less than 200 mg/dL in the perioperative period to reduce the risk for SSIs.
Implications for the Healthcare Team: The current recommendations require coordination between the teams that care for patients before, during, and after the operation. Protocols should outline responsibilities for each team member, and checklists can ensure completion of critical tasks.
