Thursday, May 4, 2017

CDC releases ‘long awaited’ guidelines for preventing surgical site infections.

courtesy: cpsi

The Center for Disease Control released it’s much awaited update to its 1999 guidelines for the prevention of surgical site infections (SSIs). The guidelines were published online May 3, 2017 in JAMA.

As the number of surgeries performed worldwide rise, so does the human and financial cost of treating this infection also rises as reimbursements for SSIs are often reduced or denied. It is estimated that 50% of SSIs are preventable.

A targeted systematic review of the literature conducted from 1998 through April 2014 identified nearly 5750 studies and abstracts, out of which 896 underwent detailed review by 2 independent reviewers. After review, about 170 studies were finally used to construe the final guidelines.

Each recommendation was graded based on the standard GRADE approach (Grading of Recommendations, Assessment, Development, and Evaluation) as strong 1A to no recommendation depending on strength of evidence for benefit and harm to the patient.

The recommendations are:

In elective surgeries, the patients should take a shower or full body bath with antimicrobial or nonantimicrobial soap, antiseptic agent not earlier than night before the day of surgery. (Category IB)

Preoperative antimicrobial agents should only be administered when indicated according to clinical practice guidelines, at such time that the bactericidal levels of agent is achieved at the time of tissue incision. No specific timing recommendation is possible at this stage because of insufficient evidence at present.

In cesarean section, parenteral prophylactic antimicrobial agent is indicated before the skin incision is given. (Category IA–strong recommendation; high-quality evidence.)

At this time no recommendation is made for weight-adjusted parenteral antimicrobial prophylaxis dosing or redosing of parenteral antibiotics during the surgical procedure.  

Skin preparation should be done with alcohol based antiseptic agents. (Category IA–strong recommendation; high to moderate–quality evidence.)

No recommendation is made for intraoperative antimicrobial irrigation (eg, intra-abdominal, deep, or subcutaneous tissues) for the prevention of SSIs.

A recommendation is made for NOT to apply any antimicrobial cream, ointment or powder to the surgical incision. (Category IB–strong recommendation; low-quality evidence.)

Applying antimicrobial dressings after primary closure is also not recommended because of lack of strong evidence.

All patients who are diabetic or non-diabetic should have blood glucose levels less than 200 mg/dL during and after surgery. (Category IA–strong recommendation; high to moderate–quality evidence.)

Evidence also suggest for maintaining perioperative normothermia to reduce the risk of SSIs. (Category IA–strong recommendation; high to moderate–quality evidence.)

Patients undergoing surgery under general anesthesia, should be given high fraction oxygen during surgery and after extubation in the immediate postoperative period.

Evidence does not favor the application of microbial sealant or plastic adhesive drapes with or without antimicrobial properties after intraoperative skin preparation.

In clean and clean-contaminated procedures, do not administer additional prophylactic antimicrobial agent doses after the surgical incision is closed in the operating room, even in the presence of a drain. (Category IA–strong recommendation; high-quality evidence.)

Insufficient evidence also exist about repeat application of antiseptic agents to the patient’s skin immediately before closing the surgical incision.

The recommendation also advise to not to withhold giving of necessary blood products from surgical patients as a means to prevent SSIs.

The recommendations provided a total of 42 statement, with 8 category 1A, 4 category 1B, 5 category II and 25 issues for which no recommendation was made because of insufficient evidence of benefit or harm.

The authors agree that “The number of unresolved issues in this guideline reveals substantial gaps that warrant future research. 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.”

"Adequately powered, well-designed studies that assess the effect of specific interventions on the incidence of SSIs are needed to address these evidence gaps," they further add.

An invited commentary by 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 was also published in the journal.

Dr Lipsett opined that 25 unresolved issues, specifically in areas of orthopedics and joint replacement surgery shows that we need to focus more on clinical trials.

She also said that "There is a lot of opportunity to learn how we can provide more effective care to our patients."

She further added that the guidelines are useful for telling surgeons "what we should do and what we do not know."

The full text of the article in JAMA can be accessed here.
The commentary in JAMA can be accessed here.

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  1. The article did not say, what category is the "giving of high fraction oxygen during surgery and after extubation in the immediate postoperative period".

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