CDC Guideline: Parenteral Antimicrobial Prophylaxis for the Prevention of Surgical Site Infection
JAMA Surgery:
Surgical site infections (SSIs) are infections of the incision or organ or space that occur after surgery. Surgical patients initially seen with more complex comorbidities and the emergence of antimicrobial-resistant pathogens increase the cost and challenge of treating SSIs. The prevention of SSI is increasingly important. It has been estimated that approximately half of SSIs are preventable by application of evidence-based strategies.
Parenteral Antimicrobial Prophylaxis (AMP)
Q. What are the most effective strategies for administering parenteral AMP to reduce the risk of SSI?
1. What is the optimal timing of preoperative AMP?
Administer preoperative antimicrobial agents 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.
No further refinement of timing can be made for preoperative antimicrobial agents based on clinical outcomes.
Other guidelines
And other clinical practice guidelines recommend that administration should be within 60 minutes prior to incision. This is considered accepted practice.
2. What is the optimal timing of AMP in cesarean section: prior to skin incision or at cord clamping?
Administer the appropriate parenteral prophylactic antimicrobial agents before skin incision in all cesarean section procedures.
Other guidelines
Clinical practice guidelines based on a review of the evidence and expert opinion recommend administration of a single preoperative prophylactic antimicrobial agent by the intravenous route, based on the agent pharmacokinetics, commonly beginning within 60 minutes prior to skin incision in both elective and emergency cesarean section. Administration of AMP after cord clamping is no longer recommended.
3. How safe and effective is weight-adjusted AMP dosing?
The literature search did not identify randomized controlled trials that evaluated the benefits and harms of weight-adjusted parenteral antimicrobial prophylaxis dosing and its effect on the risk of SSI.
Other guidelines
Clinical practice guidelines based on a review of the evidence and expert opinion recommend increasing the single preoperative prophylactic antimicrobial agent dose for select prophylactic antimicrobial agents in obese and morbidly obese patients.
4. How safe and effective is intraoperative redosing of AMP?
The search did not identify sufficient randomized controlled trial evidence to evaluate the benefits and harms of intraoperative redosing of parenteral prophylactic antimicrobial agents for the prevention of SSI.
Other guidelines
Clinical practice guidelines based on a review of the evidence and expert opinion recommend prophylactic antimicrobial agent redosing in cases of prolonged procedures (when the procedure exceeds the half-life of the prophylactic antimicrobial agent or is longer than 3-4 hours) and in patients with major blood loss (>1,500 ml) or extensive burns.
Redosing should also be performed at intervals of 1-2 times the prophylactic antimicrobial agent half-life, starting at the beginning of the preoperative dose.
No recommendations are provided for optimal prophylactic antimicrobial agent dosing in obese and morbidly obese patients when redosing.
5. How safe and effective is postoperative AMP and what is the optimal duration?
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.
High-quality evidence suggested no benefit of continuing AMP after intraoperative closure of the surgical incisions.
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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 exclusions, 170 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.
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