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Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017

Educational Objective
To use updated evidence-based guidelines for the prevention of surgical site infections.
1 Credit CME
Abstract

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 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.

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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Article Information

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 (ecstone@cdc.gov).

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.

References
1.
National Healthcare Safety Network, Centers for Disease Control and Prevention. Surgical site infection (SSI) event. http://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf. Published January 2017. Accessed January 25, 2017.
2.
Fry  DE.  Fifty ways to cause surgical site infections.  Surg Infect (Larchmt). 2011;12(6):497-500.PubMedGoogle ScholarCrossref
3.
Anderson  DJ, Kirkland  KB, Kaye  KS,  et al.  Underresourced hospital infection control and prevention programs: penny wise, pound foolish?  Infect Control Hosp Epidemiol. 2007;28(7):767-773.PubMedGoogle ScholarCrossref
4.
Centers for Disease Control and Prevention. The direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of prevention. http://www.cdc.gov/hai/pdfs/hai/scott_costpaper.pdf. Published 2009. Accessed January 25, 2017.
5.
Stone  PW, Braccia  D, Larson  E.  Systematic review of economic analyses of health care–associated infections.  Am J Infect Control. 2005;33(9):501-509.PubMedGoogle ScholarCrossref
6.
Cullen  KA, Hall  MJ, Golosinskiy  A. Ambulatory surgery in the United States, 2006. National Health Statistics Reports 11. http://www.cdc.gov/nchs/data/nhsr/nhsr011.pdf. Revised September 4, 2009. Accessed January 25, 2017.
7.
DeFrances  CJ, Podgornik  MN.  2004 National Hospital Discharge Survey.  Adv Data. 2006;(371):1-19.PubMedGoogle Scholar
8.
US Department of Health and Human Services. National action plan to prevent health care–associated infections: road map to elimination. https://health.gov/hcq/prevent-hai-action-plan.asp. Published 2013. Accessed January 25, 2017.
9.
Centers for Medicare and Medicaid Services (CMS), HHS.  Medicare Program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system changes and FY2011 rates; provider agreements and supplier approvals; and hospital conditions of participation for rehabilitation and respiratory care services; Medicaid program: accreditation for providers of inpatient psychiatric services. Final rules and interim final rule with comment period.  Fed Regist. 2010;75(157):50041-50681.PubMedGoogle Scholar
10.
US Government Printing Office. The Deficit Reduction Act of 2005. http://www.gpo.gov/fdsys/pkg/BILLS-109s1932enr/pdf/BILLS-109s1932enr.pdf. Published 2006. Accessed January 25, 2017.
11.
Umscheid  CA, Mitchell  MD, Doshi  JA, Agarwal  R, Williams  K, Brennan  PJ.  Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs.  Infect Control Hosp Epidemiol. 2011;32(2):101-114.PubMedGoogle ScholarCrossref
12.
Guyatt  GH, Oxman  AD, Kunz  R,  et al; GRADE Working Group.  Going from evidence to recommendations.  BMJ. 2008;336(7652):1049-1051.PubMedGoogle ScholarCrossref
13.
Guyatt  GH, Oxman  AD, Kunz  R, Vist  GE, Falck-Ytter  Y, Schünemann  HJ; GRADE Working Group.  What is “quality of evidence” and why is it important to clinicians?  BMJ. 2008;336(7651):995-998.PubMedGoogle ScholarCrossref
14.
Guyatt  GH, Oxman  AD, Vist  GE,  et al; GRADE Working Group.  GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.  BMJ. 2008;336(7650):924-926.PubMedGoogle ScholarCrossref
15.
Schünemann  HJ, Oxman  AD, Brozek  J,  et al; GRADE Working Group.  Grading quality of evidence and strength of recommendations for diagnostic tests and strategies.  BMJ. 2008;336(7653):1106-1110.PubMedGoogle ScholarCrossref
16.
Umscheid CA, Agarwal RK, Brennan PJ; Healthcare Infection Control Practices Advisory Committee, Centers for Disease Control and Prevention. Updating the guideline methodology of the Healthcare Infection Control Practices Advisory Committee (HICPAC). http://www.cdc.gov/hicpac/pdf/guidelines/2009-10-29HICPAC_GuidelineMethodsFINAL.pdf. Published 2010. Accessed January 25, 2017.
17.
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):264-273.PubMedGoogle ScholarCrossref
18.
Mangram  AJ, Horan  TC, Pearson  ML, Silver  LC, Jarvis  WR; Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee.  Guideline for prevention of surgical site infection, 1999.  Am J Infect Control. 1999;27(2):97-132.PubMedGoogle ScholarCrossref
19.
Mu  Y, Edwards  JR, Horan  TC, Berríos-Torres  SI, Fridkin  SK.  Improving risk-adjusted measures of surgical site infection for the National Healthcare Safety Network.  Infect Control Hosp Epidemiol. 2011;32(10):970-986.PubMedGoogle ScholarCrossref
20.
McKibben  L, Horan  T, Tokars  JI,  et al; Heathcare Infection Control Practices Advisory Committee.  Guidance on public reporting of healthcare-associated infections: recommendations of the Healthcare Infection Control Practices Advisory Committee.  Am J Infect Control. 2005;33(4):217-226.PubMedGoogle ScholarCrossref
21.
Bozic  KJ, Ries  MD.  The impact of infection after total hip arthroplasty on hospital and surgeon resource utilization.  J Bone Joint Surg Am. 2005;87(8):1746-1751.PubMedGoogle Scholar
22.
Kurtz  SM, Lau  E, Watson  H, Schmier  JK, Parvizi  J.  Economic burden of periprosthetic joint infection in the United States.  J Arthroplasty. 2012;27(8)(suppl):61-5.e1.PubMedGoogle ScholarCrossref
23.
Engemann  JJ, Carmeli  Y, Cosgrove  SE,  et al.  Adverse clinical and economic outcomes attributable to methicillin resistance among patients with Staphylococcus aureus surgical site infection.  Clin Infect Dis. 2003;36(5):592-598.PubMedGoogle ScholarCrossref
24.
HCUPnet. Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. 2011 Nationwide Inpatient Sample (NIS). https://www.hcup-us.ahrq.gov/nisoverview.jsp. Published 2011. Accessed January 25, 2017.
25.
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):780-785.PubMedGoogle Scholar
26.
Kurtz  SM, Lau  E, Schmier  J, Ong  KL, Zhao  K, Parvizi  J.  Infection burden for hip and knee arthroplasty in the United States.  J Arthroplasty. 2008;23(7):984-991.PubMedGoogle ScholarCrossref
27.
Kurtz  SM, Ong  KL, Schmier  J, Zhao  K, Mowat  F, Lau  E.  Primary and revision arthroplasty surgery caseloads in the United States from 1990 to 2004.  J Arthroplasty. 2009;24(2):195-203.PubMedGoogle ScholarCrossref
28.
Bozic  KJ, Kurtz  SM, Lau  E,  et al.  The epidemiology of revision total knee arthroplasty in the United States.  Clin Orthop Relat Res. 2010;468(1):45-51.PubMedGoogle ScholarCrossref
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