New expert guidance for the prevention of surgical-site infections (SSIs) recommends that antibiotic prophylaxis (prevention) be discontinued when a patient's incision is closed.
That's among the most significant changes in the updated guidelines for preventing SSIs in acute care hospitals, published yesterday in Infection Control & Hospital Epidemiology by a panel of experts affiliated with the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control, The Joint Commission, and the Centers for Disease Control and Prevention (CDC). The previous version of the guidelines was published in 2014.
SSIs occur in an estimated 1% to 3% of patients undergoing surgery and are associated with an increased risk of death and higher healthcare costs. In 2021 21,186 SSIs were reported to the CDC Healthcare Safety Network, which tracks healthcare-associated infections (HAIs) in US hospitals. The experts say up to 60% of SSIs could be prevented if evidence-based guidelines are followed.
"Many surgical site infections are preventable," Michael Calderwood, MD, MPH, lead author of the updated guidelines and Chief Quality Officer at Dartmouth Hitchcock Medical Center in Lebanon, New Hampshire, said in a SHEA press release. "Ensuring that healthcare personnel know, utilize, and educate others on evidence-based prevention practices is essential to keeping patients safe during and after their surgeries."
No evidence that continuing antibiotics after surgery helps
In the guidelines, administration of antibiotics within 1 hour prior to incision is listed as the first "essential practice" for preventing SSIs, meaning that it should be adopted by all acute care hospitals.
The purpose of antibiotic prophylaxis prior to surgery is to prevent the spread of bacteria that could cause an infection. The antibiotic selected should be based on the surgical procedure, the pathogens known to cause SSI for the specific procedure, and published recommendations.
But the modified guidance now emphasizes discontinuing antibiotics after incisional closure in the operating room. The authors say that while some guidelines suggest stopping antibiotics within 24 hours of surgery, there is no evidence that antibiotics given after the incision is closed contribute to reduced SSIs, even when drains are inserted. They also note that antibiotics given after closure can contribute to Clostridioides difficile infection, antibiotic resistance, and acute kidney injury.
Ensuring that healthcare personnel know, utilize, and educate others on evidence-based prevention practices is essential to keeping patients safe during and after their surgeries.
Another recommendation now considered an essential practice is the use of parenteral and oral antibiotics before elective colorectal surgery. This is based on a meta-analysis of 40 studies that found the combination of parenteral and oral antibiotics and mechanical bowel preparation prior to elective colorectal surgery significantly reduces SSIs.
Other new essential practices include decolonization of surgical patients with an anti-staphylococcal agent prior to cardiothoracic and orthopedic procedures to reduce post-operative Staphylococcus aureus infections, and the use of a vaginal preparation with an antiseptic solution prior to cesarean delivery or hysterectomy.
Additional topics covered in the updated guidance include specific risk factors for SSIs, surveillance methods, infrastructure requirements, use of antiseptic wound lavage, and sterile reprocessing in the operating room. There are also recommendations listed as "additional approaches," which the authors say are likely to reduce SSIs but may have a low quality of evidence or may be linked to undesirable outcomes.
"Hospitals can prioritize their efforts by initially implementing infection prevention approaches listed as essential practices," the authors wrote. "If HAI surveillance or other risk assessments suggest that there are ongoing opportunities for improvement, hospitals should consider adopting some or all of the infection prevention approaches listed as additional approaches."
