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This guideline focuses on select areas for the prevention of SSI deemed important to undergo evidence assessment for the advancement of the field. This guideline was a systematic review of the literature. No institutional review board approval or participant informed consent was necessary. To provide explicit links between the evidence and recommendations, a modified Grading of Recommendations, Assessment, Development, and Evaluation GRADE approach was used for evaluating the quality of evidence and determining the strength of recommendations.

These recommendations are found in eAppendix 1 of the Supplement. A detailed description of the Guideline Questions, Scope and Purpose, and Methods, as well as the Evidence Summaries supporting the evidence-based recommendations, can also be found in eAppendix 1 of the Supplement. Results of the entire study selection process are shown in the Figure. Evidence-based recommendations in this guideline were cross-checked with those from other guidelines identified in a systematic search.

CDC completed a draft of the guideline and shared it with the expert panel for in-depth review and then with HICPAC and members of the public at committee meetings June to July CDC posted notice in the Federal Register for the following 2 periods of public comment: from January 29 to February 28, , and from April 8 to May 8, Based on the comments received, the literature search was updated, and new data were incorporated into a revised draft.

Recommendations were categorized using the following standard system that reflects the level of supporting evidence or regulations:. Category IA: A strong recommendation supported by high to moderate—quality evidence suggesting net clinical benefits or harms. Category IB: A strong recommendation supported by low-quality evidence suggesting net clinical benefits or harms or an accepted practice eg, aseptic technique supported by low to very low—quality evidence.

Category II: A weak recommendation supported by any quality evidence suggesting a trade-off between clinical benefits and harms. In , approximately 80 million surgical procedures were performed in the United States at inpatient hospitals 46 million 7 and ambulatory hospital—affiliated or freestanding 32 million settings. 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.

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Category IB—strong recommendation; accepted practice. No further refinement of timing can be made for preoperative antimicrobial agents based on clinical outcomes. Administer the appropriate parenteral prophylactic antimicrobial agents before skin incision in all cesarean section procedures.

Category IA—strong recommendation; high-quality evidence. 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 organizations have made recommendations based on observational and pharmacokinetic data, and a summary of these recommendations can be found in the Other Guidelines section of the narrative summary for this question eAppendix 1 of the Supplement.

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. Quiz Ref ID In clean and clean-contaminated procedures, do not administer additional prophylactic antimicrobial agent doses after the surgical incision is closed in the operating room, Quiz Ref ID even in the presence of a drain.

Randomized controlled trial evidence suggested uncertain trade-offs between the benefits and harms regarding intraoperative antimicrobial irrigation eg, intra-abdominal, deep, or subcutaneous tissues for the prevention of SSI. Other organizations have made recommendations based on the existing evidence, and a summary of these recommendations can be found in the Other Guidelines section of the narrative summary for this question eAppendix 1 of the Supplement.

The search did not identify randomized controlled trials that evaluated soaking prosthetic devices in antimicrobial solutions before implantation for the prevention of SSI. Do not apply antimicrobial agents ie, ointments, solutions, or powders to the surgical incision for the prevention of SSI. Category IB—strong recommendation; low-quality evidence. Application of autologous platelet-rich plasma is not necessary for the prevention of SSI. Category II—weak recommendation; moderate-quality evidence suggesting a trade-off between clinical benefits and harms.

Consider the use of triclosan-coated sutures for the prevention of SSI. Randomized controlled trial evidence suggested uncertain trade-offs between the benefits and harms regarding antimicrobial dressings applied to surgical incisions after primary closure in the operating room for the prevention of SSI.

Category IA—strong recommendation; high to moderate—quality evidence. Other organizations have made recommendations based on observational evidence, and a summary of these recommendations can be found in the Other Guidelines section of the narrative summary for this question eAppendix 1 of the Supplement. The search did not identify randomized controlled trials that evaluated the optimal hemoglobin A1C target levels for the prevention of SSI in patients with and without diabetes.

Maintain perioperative normothermia. The search did not identify randomized controlled trials that evaluated strategies to achieve and maintain normothermia, the lower limit of normothermia, or the optimal timing and duration of normothermia for the prevention of SSI.

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Randomized controlled trial evidence suggested uncertain trade-offs between the benefits and harms regarding the administration of increased fraction of inspired oxygen Fio 2 via endotracheal intubation during only the intraoperative period in patients with normal pulmonary function undergoing general anesthesia for the prevention of SSI. Quiz Ref ID For patients with normal pulmonary function undergoing general anesthesia with endotracheal intubation, administer increased Fio 2 during surgery and after extubation in the immediate postoperative period.

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To optimize tissue oxygen delivery, maintain perioperative normothermia and adequate volume replacement. Category IA—strong recommendation; moderate-quality evidence. Randomized controlled trial evidence suggested uncertain trade-offs between the benefits and harms regarding the administration of increased Fio 2 via face mask during the perioperative period in patients with normal pulmonary function undergoing general anesthesia without endotracheal intubation or neuraxial anesthesia ie, spinal, epidural, or local nerve blocks for the prevention of SSI.

Randomized controlled trial evidence suggested uncertain trade-offs between the benefits and harms regarding the administration of increased Fio 2 via face mask or nasal cannula during only the postoperative period in patients with normal pulmonary function for the prevention of SSI. The search did not identify randomized controlled trials that evaluated the optimal target level, duration, and delivery method of Fio 2 for the prevention of SSI.

Other organizations have made recommendations based on observational studies, and a summary of these recommendations can be found in the Other Guidelines section of the narrative summary for this question eAppendix 1 of the Supplement.

Otitis Externa: A Practical Guide to Treatment and Prevention

Advise patients to shower or bathe full body with soap antimicrobial or nonantimicrobial or an antiseptic agent on at least the night before the operative day. Randomized controlled trial evidence suggested uncertain trade-offs between the benefits and harms regarding the optimal timing of the preoperative shower or bath, the total number of soap or antiseptic agent applications, or the use of chlorhexidine gluconate washcloths for the prevention of SSI.

Quiz Ref ID Perform intraoperative skin preparation with an alcohol-based antiseptic agent unless contraindicated. Application of a microbial sealant immediately after intraoperative skin preparation is not necessary for the prevention of SSI. Category II—weak recommendation; low-quality evidence suggesting a trade-off between clinical benefits and harms. The use of plastic adhesive drapes with or without antimicrobial properties is not necessary for the prevention of SSI. Category II—weak recommendation; high to moderate—quality evidence suggesting a trade-off between clinical benefits and harms.

Consider intraoperative irrigation of deep or subcutaneous tissues with aqueous iodophor solution for the prevention of SSI.


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Intraperitoneal lavage with aqueous iodophor solution in contaminated or dirty abdominal procedures is not necessary. The search did not identify randomized controlled trials that evaluated soaking prosthetic devices in antiseptic solutions before implantation for the prevention of SSI.

On Infection Prevention & Control | Joint Commission

Prevention efforts should target all surgical procedures but especially those in which the human and financial burden is greatest. In , primary total knee arthroplasty accounted for more than half of the 1. By , prosthetic joint arthroplasties are projected to increase to 3.


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  4. Infection is the most common indication for revision in total knee arthroplasty 28 and the third most common indication in total hip arthroplasty. Available evidence suggested uncertain trade-offs between the benefits and harms of blood transfusions on the risk of SSI in prosthetic joint arthroplasty. Other organizations have made recommendations on this topic, and a reference to these recommendations can be found in the Other Guidelines section of the narrative summary for this question eAppendix 1 of the Supplement.

    Do not withhold transfusion of necessary blood products from surgical patients as a means to prevent SSI. Available evidence suggested uncertain trade-offs between the benefits and harms of systemic corticosteroid or other immunosuppressive therapies on the risk of SSI in prosthetic joint arthroplasty. For prosthetic joint arthroplasty patients receiving systemic corticosteroid or other immunosuppressive therapy, recommendation 1E applies: in clean and clean-contaminated procedures, do not administer additional antimicrobial prophylaxis doses after the surgical incision is closed in the operating room, even in the presence of a drain.

    Available evidence suggested uncertain trade-offs between the benefits and harms of the use and timing of preoperative intra-articular corticosteroid injection on the incidence of SSI in prosthetic joint arthroplasty.

    A Practical Guide for the Practitioner

    Available evidence suggested uncertain trade-offs between the benefits and harms of venous thromboembolism prophylaxis on the incidence of SSI in prosthetic joint arthroplasty. Other organizations have made recommendations based on the existing evidence, and these references can be found in the Other Guidelines section of the narrative summary for this question eAppendix 1 of the Supplement. Available evidence suggested uncertain trade-offs between the benefits and harms of orthopedic space suits or the health care personnel who should wear them for the prevention of SSI in prosthetic joint arthroplasty.

    In prosthetic joint arthroplasty, recommendation 1E applies: in clean and clean-contaminated procedures, do not administer additional antimicrobial prophylaxis doses after the surgical incision is closed in the operating room, even in the presence of a drain. Available evidence suggested uncertain trade-offs between the benefits and harms regarding cement modifications and the prevention of biofilm formation or SSI in prosthetic joint arthroplasty.

    The search did not identify studies evaluating prosthesis modifications for the prevention of biofilm formation or SSI in prosthetic joint arthroplasty. The search did not identify studies evaluating vaccines for the prevention of biofilm formation or SSI in prosthetic joint arthroplasty.