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 commentary in JAMA can be accessed here.
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