CDC Issues Guidelines to Halt Surgical Site Infections


The CDC has issued long-awaited recommendations for the prevention of surgical site infections.

Replacing a guideline from 1999, this is the first SSI guideline from the CDC to use current evidence-based guideline methods rather than expert opinion.

The document covers 14 areas of surgical care and offers 12 “strong” recommendations. Of these, eight are considered category 1A recommendations, supported by high- to moderate-quality evidence suggesting net clinical benefits or harms.

Among the chief recommendations:

• Patients should shower or bathe with soap or an antiseptic agent at least the night before an operation.

• Antimicrobial prophylaxis should be administered only when indicated based on published guidelines and timed such that a bactericidal concentration of the agents is established in the serum and tissues when the incision is made.

• In cesarean delivery procedures, antimicrobial prophylaxis should be administered before skin incision.

• Skin preparation in the operating room should be performed using an alcohol-based agent, unless contraindicated.

• For clean and clean-contaminated procedures, additional prophylactic antimicrobial agent doses should not be administered after the surgical incision is closed in the OR, even in the presence of a drain.

• Topical antimicrobial agents should not be applied to the surgical incision.

• During surgery, glycemic control should be implemented using blood glucose target levels less than 200 mg/dL, and normothermia should be maintained in all patients.

• Increased fraction of inspired oxygen should be administered during surgery and extubation in the immediate postoperative period for patients with normal pulmonary function undergoing general anesthesia with endotracheal intubation.

• Transfusion of blood products should not be withheld from surgical patients as a means to prevent SSIs.

These recommendations “should be incorporated into comprehensive surgical quality improvement programs to improve patient safety,” wrote the authors, who represent fields of surgery, nursing, anesthesia and health care infection control.

As important as the recommendations are, the authors found 25 areas of insufficient evidence to make recommendations. These reveal substantial gaps that warrant future research, said the authors, led by Sandra I. Berrios-Torres, MD, from the CDC’s Division of Healthcare Quality Promotion, in Atlanta.

Dr. Berrios-Torres and her colleagues argued that prevention of SSIs will become increasingly important as the number of surgical procedures in the United States rises and surgical patients present with increasingly complex comorbidities.

It is estimated that approximately half of SSIs are deemed preventable using evidence-based strategies, they said.

In the last 1.5 years, the World Health Organization and the American College of Surgeons/Surgical Infection Society also published guidelines for SSI prevention. There are some discrepancies in recommendations among the three guidelines on topics such as glucose control, with the CDC calling for target blood glucose levels less than 200 mg/dL in patients with and without diabetes and the ACS/SIS setting target levels at 110 to 150 mg/dL for all patients, regardless of their diabetic status.

The WHO and ACS/SIS made a number of recommendations based on observational studies; the CDC used a strict process for literature review, development of consensus, public reporting and refining of final recommendations.

In an invited commentary, Pamela A. Lipsett, MD, the Warfield M. Firor Endowed Professor of Surgery at the Johns Hopkins University School of Medicine, in Baltimore, said the CDC guidelines will be useful to surgeons because they are brief and summarize the recommendations, along with their level of support.

However, Dr. Lipsett expressed concern about the recommendation to avoid antibiotics in clean and clean-contaminated cases where the patient has a drain. “These recommendations are likely 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.”

Dr. Lipsett also highlighted the recommendation for a higher fraction of inspired oxygen in patients with normal pulmonary function having general endotracheal anesthesia during surgery and after extubation. All recent guidelines include this recommendation, she said, but it is “based on moderate evidence and is controversial regarding lack of potential efficacy and potential harms.”

The recommendations do not call for big changes but refinements to surgical practice, said Heather L. Evans, MD, associate professor of surgery at the University of Washington, in Seattle. But even small changes, such as expanding the indications for glucose control to nondiabetic patients, require collaboration between the services within a hospital that coordinate perioperative care.

Dr. Evans, who is studying a patient-centered health app designed to improve early diagnosis and treatment of SSIs, said the best approach to adoption of new guidelines is for surgeons to work with a multidisciplinary committee that includes key stakeholders at their hospitals. It should include infection preventionists, environmental services personnel, perioperative nurses and technologists, anesthesiologists, and certified registered nurse anesthetists and anesthesia technologists, as well as preoperative personnel in the surgery and preanesthesia clinics.

It “is a complicated endeavor, but perioperative process change requires buy-in from all,” Dr. Evans said. The guidelines also can be used to drop expensive, cumbersome practices that are not supported by evidence, she added.

The authors conducted a review of the literature for potentially relevant studies published between 1998 and 2014. A modified GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach was used to assess the quality of evidence and the strength of the resulting recommendations. Of more than 5,700 studies initially considered, 170 were used to develop the recommendations.

The guideline authors emphasized the “paucity of robust evidence,” saying it created challenges in formulating recommendations. Of the 42 SSI prevention strategies considered in the guidelines, 25 concluded with no recommendation or as an unresolved issue. These included areas such as weight-adjusted and/or intraoperative redosing of parenteral antimicrobial prophylaxis, intraoperative antimicrobial irrigation, soaking of prosthetic devices in antimicrobial solutions before implantation, and use of antimicrobial dressings applied to surgical incisions after primary closure in the OR.

More evidence on infection prevention is needed in prosthetic joint arthroplasty, the authors noted.

By 2030, prosthetic joint arthroplasties are projected to increase to 3.8 million procedures per year, and the infection risk is also expected to rise for total hip and knee arthroplasty from 2.18% to 6.5% and 6.8%, respectively. As a result, the number of hip and knee prosthetic joint infections is projected to hit 221,500 cases per year by 2030 at a cost of more than $1.62 billion.