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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.
To provide new and updated evidence-based recommendations for the prevention of SSI.
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 5759 titles and abstracts screened, 896 underwent full-text review by 2 independent reviewers. After exclusions, 170 studies were extracted into evidence tables, appraised, and synthesized.
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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Accepted for Publication: March 1, 2017.
Corresponding Author: Erin C. Stone, MA, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, 1660 Clifton Rd NE, Mail Stop A07 Atlanta, GA 30329 (email@example.com).
Correction: This article was corrected on June 21, 2017, to fix corrupted numbering and update abstract and methods.
Published Online: May 3, 2017. doi:10.1001/jamasurg.2017.0904
Author Contributions: Dr Umscheid and Ms Stone had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Berríos-Torres, Umscheid, Bratzler, Leas, Stone, Kelz, Morgan, Mazuski, Dellinger, Itani, Berbari, Parvizi, Blanchard, Kluytmans.
Acquisition, analysis, or interpretation of data: Berríos-Torres, Umscheid, Bratzler, Leas, Stone, Kelz, Reinke, Morgan, Solomkin, Mazuski, Dellinger, Segreti, Allen, Kluytmans, Donlan, Schecter.
Drafting of the manuscript: Berríos-Torres, Umscheid, Leas, Stone, Kelz, Reinke, Morgan, Itani, Berbari, Segreti, Blanchard.
Critical revision of the manuscript for important intellectual content: Berríos-Torres, Umscheid, Bratzler, Leas, Stone, Kelz, Reinke, Solomkin, Mazuski, Dellinger, Itani, Berbari, Segreti, Parvizi, Allen, Kluytmans, Donlan, Schecter.
Statistical analysis: Berríos-Torres, Umscheid, Leas.
Administrative, technical, or material support: Berríos-Torres, Bratzler, Leas, Stone, Morgan, Itani, Parvizi.
Study supervision: Berríos-Torres, Umscheid, Bratzler, Stone, Itani, Berbari, Parvizi.
Conflict of Interest Disclosures: Drs Umscheid, Kelz, and Morgan and Mr Leas reported receiving funding from the Centers for Disease Control and Prevention to support the guideline development process. Dr Bratzler reported being a consultant for the Oklahoma Foundation for Medical Quality and for Telligen (a nonprofit Medicaid external quality review organization) and reported that his institution received payment for his lectures, including service on speakers’ bureaus from Premier and Janssen Pharmaceuticals. Dr Reinke reported receiving lecture fees from Covidien and reported being a paid consultant for Teleflex. Dr Solomkin reported receiving grants for clinical research from, receiving consulting fees regarding clinical trial data, serving on an advisory board for, or lecturing for honoraria from the following: Merck, Actavis, AstraZeneca, PPD, Tetraphase, Johnson & Johnson, and 3M. Dr Mazuski reported being a paid consultant for Bayer, Cubist Pharmaceuticals, Forest Laboratories, MedImmune, Merck/Merck Sharp and Dohme, and Pfizer; reported receiving lecture fees from Forest Laboratories, Merck/Merck Sharp and Dohme, and Pfizer; and reported that his institution received funding for his consultancy to AstraZeneca and grants from AstraZeneca, Bayer, Merck/MSD, and Tetraphase. Dr Dellinger reported receiving grants for clinical research from, serving on an advisory board for, or lecturing for honoraria from the following: Merck, Baxter, Ortho-McNeil, Targanta, Schering-Plough, WebEx, Astellas, Care Fusion, Durata, Pfizer, Applied Medical, Rib-X, Affinium, and 3M. Dr Itani reported that his institution received grants from Merck, Cubist, Dr Reddy’s, Sanofi Pasteur, and Trius for research trials; reported clinical advisory board membership at Forrest Pharmaceuticals; and reported payment for development of educational presentations for Med Direct and Avid Education. Dr Berbari reported that his institution received a grant from Pfizer for a research trial for which he serves as the principal investigator. Dr Segreti reported receiving lecture fees from Pfizer, Merck, and Forest Laboratories and reported owning stocks in or having stock options from Pfizer. Dr Parvizi reported being a paid consultant for Zimmer, Smith and Nephew, ConvaTec, TissueGene, CeramTech, and Medtronic; reported receiving royalties from Elsevier, Wolters Kluwer, Slack Incorporated, Data Trace Publishing, and Jaypee Brothers Medical Publishers; and reported having stock options with Hip Innovation Technologies, CD Diagnostics, and PRN. Dr Allen reported receiving lecture fees from Ethicon and royalties from Wolters Kluwer as an author for Infection Control: A Practical Guide for Healthcare Facilities. Dr Kluytmans reported being a paid consultant for 3M, Johnson & Johnson, and Pfizer. No other disclosures were reported.
Funding/Support: The Centers for Disease Control and Prevention (CDC) supported the development of the guideline. The activities of Drs Umscheid, Kelz, and Morgan and Mr Leas were supported through a short-term detail under contract at CDC (10IPA1004117, 10IPA1004133, 11IPA1106551, 11IPA1106555, and 11IPA1106565).
Role of the Funder/Sponsor: Centers for Disease Control and Prevention conducted the full guideline development process, directing the design and conduct of the systematic reviews; collection, management, analysis, and interpretation of the data; and preparation, review, and approval for submission of the manuscript for publication. Centers for Disease Control and Prevention staff members were responsible for the overall design and conduct of the guideline and preparation, review, and approval of the manuscript.
Group Information: The Healthcare Infection Control Practices Advisory Committee (HICPAC) members are as follows: Hilary M. Babcock, MD, MPH, Washington University School of Medicine in St Louis; Dale W. Bratzler, DO, MPH, The University of Oklahoma Health Sciences Center; Patrick J. Brennan, MD, University of Pennsylvania Health System; Vickie M. Brown, RN, MPH, WakeMed Health & Hospitals; Lillian A. Burns, MT, MPH, Greenwich Hospital; Ruth M. Carrico, PhD, RN, CIC, University of Louisville School of Medicine; Sheri Chernetsky Tejedor, MD, Emory University School of Medicine; Daniel J. Diekema, MD, University of Iowa Carver College of Medicine; Alexis Elward, MD, Washington University School of Medicine in St Louis; Neil O. Fishman, MD, University of Pennsylvania Health System; Ralph Gonzales, MD, MSPH, University of California, San Francisco; Mary K. Hayden, MD, Rush University Medical Center; Susan Huang, MD, MPH, University of California Irvine School of Medicine; W. Charles Huskins, MD, MSc, Mayo Clinic College of Medicine; Lynn Janssen, MS, CIC, CPHQ, California Department of Public Health; Tammy Lundstrom, MD, JD, Providence Hospital; Lisa Maragakis, MD, MPH, The Johns Hopkins Hospital; Yvette S. McCarter, PhD, University of Florida Health Science Center; Denise M. Murphy, MPH, RN, CIC, Main Line Health System; Russell N. Olmsted, MPH, St Joseph Mercy Health System; Stephen Ostroff, MD, US Food and Drug Administration; Jan Patterson, MD, University of Texas Health Science Center, San Antonio; David A. Pegues, MD, David Geffen School of Medicine at UCLA; Peter J. Pronovost, MD, PhD, The Johns Hopkins University; Gina Pugliese, RN, MS, Premier Healthcare Alliance; Selwyn O. Rogers Jr, MD, MPH, The University of Texas Medical Branch; William P. Schecter, MD, University of California, San Francisco; Barbara M. Soule, RN, MPA, CIC, The Joint Commission; Tom Talbot, MD, MPH, Vanderbilt University Medical Center; Michael L. Tapper, MD, Lenox Hill Hospital; and Deborah S. Yokoe, MD, MPH, Brigham & Women’s Hospital.
Ex Officio Members: William B. Baine, MD, Agency for Healthcare Research and Quality; Elizabeth Claverie-Williams, MS, US Food and Drug Administration; David Henderson, MD, National Institutes of Health; Jeannie Miller, RN, MPH, Centers for Medicare & Medicaid Services; Paul D. Moore, PhD, Health Resources and Services Administration; Sheila Murphey, MD, US Food and Drug Administration; and Daniel Schwartz, MD, MBA, Centers for Medicare & Medicaid Services.
Liaisons: Joan Blanchard, RN, BSN, Association of Perioperative Registered Nurses; William A. Brock, MD, Society of Critical Care Medicine; Barbara DeBaun, MSN, RN, CIC, Association of Professionals of Infection Control and Epidemiology, Inc; Kathleen Dunn, BScN, MN, RN, Public Health Agency of Canada; Sandra Fitzler, RN, American Health Care Association; Nancy Foster, American Hospital Association; Janet Franck, RN, MBA, CIC, DNV Healthcare, Inc; Diana Gaviria, MD, MPH, National Association of County and City Health Officials; Jennifer Gutowski, MPH, BSN, RN, CIC, National Association of County and City Health Officials; Holly Harmon, RN, MBA, American Health Care Association; Patrick Horine, MHA, DNV Healthcare, Inc; Michael D. Howell, MD, MPH, Society of Critical Care Medicine; W. Charles Huskins, MD, MSC, Infectious Diseases Society of America; Marion Kainer, MD, MPH, Council of State and Territorial Epidemiologists; Emily Lutterloh, MD, MPH, Association of State and Territorial Health Officials; Lisa Maragakis, MD, Society for Healthcare Epidemiology of America; Michael McElroy, MPH, CIC, America’s Essential Hospitals; Lisa McGiffert, Consumers Union; Silvia Muñoz-Price, MD, America’s Essential Hospitals; Shirley Paton, RN, MN, Public Health Agency of Canada; Michael Anne Preas, RN, CIC, Association of Professionals of Infection Control and Epidemiology, Inc; Mark E. Rupp, MD, Society for Healthcare Epidemiology of America; Mark Russi, MD, MPH, American College of Occupational and Environmental Medicine; Sanjay Saint, MD, MPH, Society of Hospital Medicine; Robert G. Sawyer, MD, Surgical Infection Society; Roslyne Schulman, MHA, MBA, American Hospital Association; Rachel Stricof, MPH, Advisory Council for the Elimination of Tuberculosis; Donna Tiberi, RN, MHA, Healthcare Facilities Accreditation Program; Margaret VanAmringe, MHS, The Joint Commission; Stephen Weber, MD, Infectious Diseases Society of America; Elizabeth Wick, MD, American College of Surgeons; Robert Wise, MD, The Joint Commission; and Amber Wood, MSN, RN, CNOR, CIC, CPN, Association of Perioperative Registered Nurses.
Disclaimer: The opinions of the reviewers might not be reflected in all of the recommendations contained in this document.
Additional Information: Before July 2014, Dr Berríos-Torres was employed at Centers for Disease Control and Prevention. She has no affiliation since July 2014. Authors recused themselves from discussions if they had competing interests related to recommendations under discussion. For product-specific recommendation discussions (eg, triclosan-coated sutures), a new declaration of conflicts specific to that topic was requested from each author before his or her input was considered in the formulation of the recommendation.
Additional Contributions: The Centers for Disease Control and Prevention thanks the many individuals and organizations who provided valuable feedback on the guideline during the development process, especially the following experts for their input throughout the process: Rajender Agarwal, MD, MPH (Center for Evidence-Based Practice, University of Pennsylvania Health System, Philadelphia); J. William Costerton, PhD (Center for Genomic Sciences, Allegheny-Singer Research Institute, Pittsburgh, Pennsylvania); Jeffrey C. Hageman, MHS (Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia); Thomas Hunt, MD (Department of Surgery, University of California at San Francisco); Bernard Morrey, MD (Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota); Lena M. Napolitano, MD (Division of Acute Care Surgery, University of Michigan Health Systems, Ann Arbor); Douglas Osmon, MD (Department of Infectious Diseases, Mayo Clinic, Rochester, Minnesota); Robin Patel, MD(CM), FRCP(C), D(ABMM) (Infectious Diseases Research Laboratory, Mayo Clinic, Rochester, Minnesota); and Mark Shirtliff, PhD (Department of Microbial Pathogenesis, University of Maryland, Baltimore). None received compensation outside of their usual salary.
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