Friday, 29 March, 2024
HomeGuidelinesCDC recommendations to prevent surgical site infections

CDC recommendations to prevent surgical site infections

Good patient and environmental hygiene and judicious use of antimicrobial therapy form the basis of new recommendations issued by the Centres for Disease Control and Prevention (CDC) for preventing surgical site infections.

Patients should shower or have a full-body bath at least the night before surgery, using soap (antimicrobial or non-antimicrobial) or an antiseptic agent, the recommendations state. Use of antimicrobial prophylaxis should adhere to published clinical guidelines, and, as indicated, administration should be timed to achieve bactericidal concentrations in serum and tissues at the time of the initial incision. Women undergoing caesarean section should receive antimicrobial prophylaxis before the incision.

Developed by the CDC Healthcare Infection Control Practices Advisory Committee, the guideline includes recommendations for skin preparation in the operating room, use of topical agents, glycaemic control, oxygen management, and use of transfusion products.

The CDC guideline "is useful to every surgeon because it is brief and summarises the recommendations, with their level of support," Dr Pamela A Lipsett, programme director of Surgical Critical Care at Johns Hopkins Medicine in Baltimore, said in an accompanying commentary. "It tells us what we should do and what we do not know."

Unfortunately, though, she added, a majority (25) of the 42 statements in the guideline come with "no recommendation with respect to support or harm if the level of the evidence was low or very low or if [the authors] were unable to judge trade-offs between harms and benefits of the proposed intervention because of lack of outcomes."

The guideline evolved from a literature review from 1998 through April 2014. Two independent reviewers conducted full-text reviews of 896 titles and abstracts, 170 of which were extracted into evidence, evaluated, and categorised.

Recommendations that emerged from the review included: use preoperative antimicrobial prophylaxis only as indicated by published clinical guidelines; do not apply topical antimicrobial agents to prevent surgical site infection; implement glycaemic control perio-peratively, and target a blood glucose level

The advisory committee that drafted the guideline acknowledged that "the number of unresolved issues in the guideline reveals substantial gaps that warrant future research. A select list of these unresolved issues may be prioritised to formulate a research agenda to advance the field."

Lipsett noted that guidelines "tell us what we can do (or not do) for most patients," and these CDC recommendations for preventing surgical site infection "do exactly that, and show us the way forward."

Abstract
Importance : The human and financial costs of treating surgical site infections (SSIs) are increasing. The number of surgical procedures performed in the United States continues to rise, and surgical patients are initially seen with increasingly complex comorbidities. It is estimated that approximately half of SSIs are deemed preventable using evidence-based strategies.
Objective: To provide new and updated evidence-based recommendations for the prevention of SSI.
Evidence Review : A targeted systematic review of the literature was conducted in MEDLINE, EMBASE, CINAHL, and the Cochrane Library from 1998 through April 2014. A modified Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach was used to assess the quality of evidence and the strength of the resulting recommendation and to provide explicit links between them. Of 5487 potentially relevant studies identified in literature searches, 5759 titles and abstracts were screened, and 896 underwent full-text review by 2 independent reviewers. After exclusions170 studies were extracted into evidence, evaluated, and categorized.
Findings: Before surgery, patients should shower or bathe (full body) with soap (antimicrobial or nonantimicrobial) or an antiseptic agent on at least the night before the operative day. Antimicrobial prophylaxis should be administered only when indicated based on published clinical practice 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 section 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 operating room, 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 after 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 SSI.
Conclusions and Relevance: This guideline is intended to provide new and updated evidence-based recommendations for the prevention of SSI and should be incorporated into comprehensive surgical quality improvement programs to improve patient safety.

Authors
Sandra I Berríos-Torres, Craig A Umscheid, Brian Leas, Erin C Stone, Rachel R Kelz, Caroline E Reinke, Sherry Morgan, Joseph S Solomkin, John E Mazuski, E Patchen Dellinger, Kamal MF Itani, Elie F Berbari, John Segreti, Javad Parvizi, Joan Blanchard, George Allen, Jan AJW Kluytmans, Rodney Donlan, William P Schecter

[link url="https://www.medpagetoday.com/hospitalbasedmedicine/infectioncontrol/65038"]MedPageToday report[/link]
[link url="http://jamanetwork.com/journals/jamasurgery/fullarticle/2623725"]JAMA Surgery abstract[/link]
[link url="http://jamanetwork.com/journals/jamasurgery/article-abstract/2623721"]JAMA Surgery invited commentary[/link]

MedicalBrief — our free weekly e-newsletter

We'd appreciate as much information as possible, however only an email address is required.