A new format and structure allows for timely updates and distribution.

The prevention of surgical site infections (SSIs) continues to be a major goal for health care in both inpatient facilities and ambulatory surgical centers (ASCs). As nurses, surgeons, physician assistants, and healthcare technicians work together to care for their surgical patients, they rely on recommendations and guidelines to help them achieve positive outcomes with zero or low rates of SSIs.

A recent prevalence study found that SSIs are the most common healthcare-associated infections (HAIs), resulting in 31% of all HAIs in hospitalized patients. Those who develop an SSI are more likely to have an extended length of hospital stay and an increased risk of hospital readmission or death.

The Centers for Disease Control and Prevention (CDC) Guideline for the Prevention of Surgical Site Infection was last updated in 1999, when the terminology “surgical site infection” was first used. The new guideline was published in May 2017, and you can access it at www.jamanetwork.com.

New structure

The new guideline structure includes a core section with new high-volume, high-burden procedure sections. It provides recommendations applicable to a spectrum of procedures that are performed daily in hospital-based operating rooms and ASCs. The guideline also includes a section specific to prosthetic joint arthroplasties because of the number of these procedures performed in the United States (about 1.2 million per year) and their association with high costs and increasing SSIs.

The new evidence-based structure of the guideline allows timely, targeted updates to be implemented as new knowledge is acquired without rewriting the entire guideline.

Methodology

Beginning in 2010, the CDC and Healthcare Infection Control Practices Advisory Committee (HICPAC) implemented a new process for how the guideline is developed and issued. The core concept and framework uses an evidence-based methodology that includes:

• formulating key questions based on experts’ opinions
• performing targeted systematic reviews of the best current evidence
• using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. (See Making the GRADE.)

Recommendations

Recommendations in this new guideline are categorized using a system that reflects the level of supporting evidence or regulation. (See Categorization recommendation scheme.) Following are selected recommendations from the 2017 guideline within both the core and prosthetic joint arthroplasty sections.

Parenteral antimicrobial prophylaxis

The 1999 Category IA recommendation for parenteral antimicrobial prophylaxis—Administer a prophylactic antimicrobial agent only when indicated, and select it based on its efficacy against the most common pathogens causing SSI for a specific operation and published recommendations—was changed to a Category IB recommendation—Administer preoperative antimicrobial agents only when indicated based on published clinical practice guidelines and timed such that a bactericidal concentration of the agent is established in the serum and tissues when the incision is made.

Making the Grade

Another 1999 Category IA recommendation—For high-risk cesarean section, administer the prophylactic antimicrobial agent immediately after the umbilical cord is clamped—was changed to a new Category IA recommendation—Administer the appropriate parenteral prophylactic antimicrobial agents before skin incision in all cesarean section procedures.

In addition, a new Category IA recommendation was included—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.

Nonparenteral antimicrobial prophylaxis

In the 1999 guideline, no recommendations existed for nonparenteral antimicrobial prophylaxis. The following recommendations were added in 2017:

• No recommendations/unresolved issue—intraoperative antimicrobial irrigation.
• No recommendations/unresolved issue—soaking prosthetic devices in antimicrobial solution before implantation for the prevention of SSI.
• Category IB—Do not apply antimicrobial agents (i.e., ointments, solutions, or powders) to the surgical incision for the prevention of SSI.
• Category II—Application of autologous platelet-rich plasma is not necessary for the prevention of SSI. 
• Category II—Consider the use of triclosan-coated sutures for the prevention of SSI.

Glycemic controls

The 1999 Category IB recommendation for glycemic controls—Adequately control serum glucose levels—was changed to another Category IB recommendation—Adequately control serum blood glucose levels in all diabetic patients and particularly avoid hyperglycemia perioperatively. Also, an updated specific Category IA recommendation was added—Implement perioperative glycemic control and use blood glucose targets less than 200 mg/dL in patients without diabetes.

Normothermia

No normothermia recommendations existed in the 1999 guideline. The new guideline includes a Category IA recommendation—Maintain perioperative normothermia.

Oxygenation

Oxygenation wasn’t covered in the 1999 guideline. The new guideline includes this Category IA recommendation—For patients with normal pulmonary function undergoing general anesthesia with endotracheal intubation, administer increased fraction of inspired oxygen (FiO2) during surgery and after extubation in the immediate postoperative period.

Categorization recommendation scheme

Antiseptic prophylaxis

Two Category IB recommendations were updated for antiseptic prophylaxis. Require patients to shower or bathe with an antiseptic agent on at least the night before the operative day was updated to a new Category IB recommendation—Advise patients to shower or bathe (full body) with soap (antimicrobial or nonantimicrobial) or an antiseptic agent on at least the night before the operative day. The 1999 recommendation—Use an appropriate antiseptic agent for skin preparation—was updated to a Category IA recommendation—Perform intraoperative skin preparation with an alcohol-based antiseptic agent unless contraindicated.

Two new Category II recommendations were added:

• The use of plastic adhesive drapes with or without antimicrobial properties is not necessary for the prevention of SSI.
• Consider intraoperative irrigation of deep or subcutaneous tissues with aqueous iodophor solution for the prevention of SSI. Intraperitoneal lavage with aqueous iodophor solution in contaminated or dirty abdominal procedures is not necessary.

Prosthetic joint arthroplasty

The new prosthetic joint arthroplasty section provides recommendations specific to primary and revision joint arthroplasty procedures, total knee arthroplasty, total hip arthroplasty, hip hemiarthroplasty, and primary shoulder, elbow, and ankle arthroplasty. The recommendations are presented under the following seven categories:

1. Blood transfusion
2. Systemic immunosuppressive therapy
3. Intraarticular corticosteroid injections
4. Anticoagulation
5. Orthopedic surgical space suit
6. Postoperative antimicrobial prophylaxis duration with drain use
7. Biofilm

Eleven of the recommendations in this section were designated as “no recommendation/unresolved issue” and are associated with blood transfusion, systemic immunosuppressive therapy, intraarticular corticosteroid injections, anticoagulation, orthopedic surgical space suit, and biofilm.

A Category IA recommendation was made for systemic immunosuppressive therapy—For prosthetic joint arthroplasty patients receiving systemic corticosteroid or other immunosuppressive therapy, in clean and clean-contaminated procedures, do not administer additional antimicrobial prophylaxis doses after the surgical incision is closed in the operating room, even in the presence of a drain. Another Category IA recommendation was made for postoperative antimicrobial prophylaxis duration with drain use—In prosthetic joint arthroplasty in clean and clean-contaminated procedures, do not administer additional antimicrobial prophylaxis doses after the surgical incision is closed in the operating room, even in the presence of a drain.

A Category IB recommendation was made for blood transfusion—Do not withhold transfusion of necessary blood products from surgical patients as a means to prevent SSI.

Opportunities

SSIs continue to be a major concern in both inpatient and ASC settings. Using the best available evidence as the framework for the new guideline is a step in the right direction and a strength of this new process for issuing recommendations from HICPAC. The ability to quickly review and update the guideline as new information becomes available, while leaving the core intact, means new evidence can be swiftly disseminated and translated into practice.

However, the new guideline demonstrates several gaps in knowledge as is indicated by the number of “no recommendations/unresolved issue” designations. This represents an opportunity for nurses to develop and participate in well-designed randomized clinical trials to generate this evidence.

George Allen is director of infection prevention at NewYork-Presbyterian Brooklyn Methodist Hospital in Brooklyn, New York.

References

Anderson DJ, Podgorny K, Berrios-Torres SI, et al. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(suppl 2):S66-88.

Berrios-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. 2017. [Epub ahead of print].

Centers for Disease Control and Prevention. Number and standard error of discharges from short-stay hospitals with and without procedures and percentage with procedures and standard error by selected characteristics: United States, 2010. Data from the CDC/NCHS National Hospital Discharge Survey, 2010. read more at cdc.gov

Fry DE. Fifty ways to cause surgical site infections. Surgl Infect. 2011;12(6):497-500.

Garner JS. CDC guideline for prevention of surgical wound infections, 1985. Supersedes guideline for prevention of surgical wound infections published in 1982. (Originally published in November 1985.) Revised. Infect Control. 1986;7(3):193-200.

GRADE Working Group. www.gradeworkinggroup.org

Hall MJ, DeFrances CJ, Williams SN, Golosinskiy A, Schwartzman A. National Hospital Discharge Survey: 2007 summary. Natl Health Stat Report. 2010;26(29):1-20, 24.

Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;
89(4):780-5.

Kurtz S, Lau E, Watson H, Schmier JK, Parvizi J. Economic burden of periprosthetic joint infection in the United States. J Arthroplasty. 2012;27(suppl 8):61-5.

Magill SS, Edwards JR, Bamberg W, et al. Multistate point-prevalence survey of health care-associated infections. N Engl J Med. 2014;370(13):1198-208.

Magill SS, Hellinger W, Cohen J, et al. Prevalence of healthcare-associated infections in acute care hospitals in Jacksonville, Florida. Infect Control Hosp Epidemiol. 2012;33(3):283-91.

Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control. 1999;27(2):97-132.

Shallwani H, Shakir HJ, Aldridge AM, Donovan MT, Levy EI, Gibbons KJ. Mandatory change from surgical skull caps to bouffant caps among operating room personnel does not reduce surgical site infections in class I surgical cases: A single-center experience with more than 15,000 patients. Neurosurgery. 2017. go to academic.oup.com

Simmons BP. Guideline for prevention of surgical wound infections. Am J Infect Control. 1983;11(4):133-43.

Umscheid CA, Agarwal RK, Brennan PJ; Healthcare Infection Control Practices Advisory Committee. Updating the guideline development methodology of the Healthcare Infection Control Practices Advisory Committee (HICPAC). Am J Infect Control. 2010;38(4):264-73.

U.S. Department of Health and Human Services. Overview: Health care–associated infections. read more at health.gov