New CDC Guidelines for SSI Prevention Leave Unanswered Questions

New guidelines for the prevention of surgical site infection (SSI) prepared by the Centers for Disease Control and Prevention (CDC) were published in a recent issue of JAMA Surgery.¹ These guidelines were designed to update the original recommendations published in 1999, before evidence-based methodologies became standard, but they left more questions open than they answered.

The multicenter team of reviewers representing the CDC Healthcare Infection Control Practices Advisory Committee analyzed and extracted recommendations from 176 relevant studies dated from 1998 to 2014 for application in reducing SSI. Using data from 2006, they reported that 80 million surgical procedures were performed that year in hospitals and ambulatory or freestanding centers in the United States.^2,3 Infectious complications from procedures were conservatively estimated at 1.9% of cases occurring between 2006 and 2009, at costs ranging from $10,000 to $25,000 per infection.^4-6

The strongest recommendations (Category IA and 1B evidence) were made in the following areas:

1. Limit the use of preoperative antimicrobials and time their use for the highest concentration at the time of incision.
2. In cesarean section procedures only, administer parenteral prophylactic antimicrobial agents before incision.
3. Do not administer prophylactic antimicrobials after closing the incision, even in the presence of drains.
4. Do not apply topical antimicrobial agents (ointments, powders, or solutions) to the surgical site.
5. Manage preoperative glucose to a target level of 200 mg/dL.
6. Maintain normal body temperature prior to surgery.
7. Increase administered fraction of inspired oxygen during surgery and after extubation.
8. Require patients to shower or bathe with antimicrobial or nonantimicrobial soap within 24 hours of surgery.
9. Prepare surgical incision site with alcohol unless contraindicated.
10. Transfusion of blood products should not be withheld to prevent SSI.
11. In prosthetic joint arthroplasty procedures where corticosteroids or immunosuppressive agents are given, do not administer prophylactic antimicrobials after closing the incision, even in the presence of drains.

Several weak recommendations were also made based on Category II evidence of high to moderate quality that suggested a trade-off between benefit and harm. Altogether, the guidelines offered 17 Category IA, Category IB, and Category II recommendations, while also leaving 25 areas open, which the authors wrote was due to a “paucity of robust evidence across the entire guideline [that] created challenges in formulating recommendations for the prevention of SSI.” They acknowledged that these challenges revealed large knowledge gaps pointing to the need for further investigation in multiple areas.

In particular, surgeries that are most dependent on technological advances — such as prosthetic joint arthroplasty — were singled out as important areas of focus for future research. “The fact that most statements were unresolved, especially regarding prosthetic joint surgery, shows our investigators where we should be putting forth our efforts in clinical trials,” wrote Pamela A. Lipsett, MD, MHPE, MCCM, in a separate commentary published in the same issue of JAMA Surgery.⁷

References

1. Berríos-Torres SI, Umscheid CA, Bratzler DW, et al; for the Healthcare Infection Control Practices Advisory Committee. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg. 2017;152(8):784-791.
2. Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the United States, 2006. National Health Statistics Reports 11. Revised September 4, 2009. Accessed August 24, 2017.
3. DeFrances CJ, Podgornik MN. 2004 National Hospital Discharge Survey.  Adv Data. 2006:371:1-19.
4. Anderson DJ, Kirkland KB, Kaye KS, Thacker PA. Underresourced hospital infection control and prevention programs: penny wise, pound foolish? Infect Control Hosp Epidemiol. 2007;28(7):767-773.
5. Scott RD. The direct medical costs of healthcare-associated infections in US hospitals and the benefits of prevention. Centers for Disease Control and Prevention.  Published March 2009. Accessed August 24, 2017
6. Stone PW, Braccia D, Larson E. Systematic review of economic analyses of healthcare–associated infections. Am J Infect Control. 2005;33(9):501-509.
7. Lipsett PA. Surgical site infection prevention-what we know and what we do not know. JAMA Surg. 2017;152(8):791-792.