Centers for Dia Control and Prevention Guideline for the Prevention of Surgical Site Infection,2017
Sandra I.Berríos-Torres,MD;Craig A.Umscheid,MD,MSCE;Dale W.Bratzler,DO,MPH;Brian Leas,MA,MS;Erin C.Stone,MA;Rachel R.Kelz,MD,MSCE;Caroline E.Reinke,MD,MSHP;Sherry Morgan,RN,MLS,PhD;Joph S.Solomkin,MD;John E.Mazuski,MD,PhD;E.Patchen Dellinger,MD;Kamal M.F.Itani,MD;Elie F.Berbari,MD;John Segreti,MD;Javad Parvizi,MD;Joan Blanchard,MSS,BSN,RN,CNOR,CIC;
George Allen,PhD,CIC,CNOR;Jan A.J.W.Kluytmans,MD;Rodney Donlan,PhD;William P.Schecter,MD;for the Healthcare Infection Control Practices Advisory Committee
Invited Commentary
Supplemental content
Author Affiliations:Author
affiliations are listed at the end of this article.
Group Information:The Healthcare Infection Control Practices Advisory Committee members are listed at the end of this article.
Corresponding Author:Erin C.Stone,MA,Division of Healthcare Quality Promotion,Centers for Dia Control and Prevention,1660Clifton Rd NE,Mail Stop A07Atlanta,GA 30329(v ).孝心作业
Clinical Review &Education
海马功效和作用JAMA Surgery |Special Communication
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S urgical site infections(SSIs)are infections of the incision or organ or space that occur after surgery.1Surgical patients ini-
tially en with more complex comorbidities2and the emer-gence of antimicrobial-resistant pathogens increa the cost and challenge of treating SSIs.3-5The prevention of SSI is increasingly im-portant as the number of surgical procedures performed in the United States continues to ri.6,7Public reporting of process,out-come,and other quality improvement measures is now required,8,9 and reimburments10for treating SSIs are being reduced or de-nied.It has been estimated that approximately half of SSIs are preventable by application of evidence-bad strategies.11
Methods
This guideline focus on lect areas for the prevention of SSI deemed important to undergo evidence asssment for the ad-vancement of the field.The areas of focus were informed by feed-back received from clinical experts and input from the Healthcare Infection Control Practices Advisory Committee(HICPAC),a fed-eral advisory committee to the Centers for Dia Control and Prevention(CDC).This guideline was a systematic review of the literature.No institutional review board approval or participant in-formed connt was necessary.
This guideline’s recommendations were developed bad on a targeted systematic review of the best available evidence on SSI prevention conducted in MEDLINE,EMBASE,CINAHL,and the Cochrane Library from1998through April2014.To provide explicit links between the evidence and recommendations,a modified Grad-ing of Recommendations,Asssment,Development,and Evalua-tion(GRADE)approach was ud for evaluating the quality of evi-dence and determining the strength of recommendations.12-15The methods and structure of this guideline were adopted in2009by CDC and HICPAC.16,17The prent guideline does not reevaluate v-eral strong recommendations offered by CDC’s1999Guideline for Prevention of Surgical Site Infection18that are now considered to be accepted practice for the prevention of SSI.The recommen-dations are found in eAppendix1of the Supplement.A detailed description of the Guideline Questions,Scope and Purpo,and Methods,as well as the Evidence Summaries supporting the evi-dence-bad recommendations,can also be found in eAppendix1 of the Supplement.
The detailed literature arch strategies,GRADE Tables,and Evidence Tables supporting each ction can be found in eAppen-dix2of the Supplement.Results of the entire study lection pro-cess are shown in the Figure.Of5759titles and abstracts screened,896underwent full-text review by2independent reviewers.Full-text articles were excluded if:1)SSI was not
Figure.Results of the Study Selection Process
CDC indicates Centers for Dia Control and Prevention;GRADE,Grading of Recommendations,Asssment,Development,and Evaluation;RCTs,randomized controlled trials;SRs,expand;and SSI,surgical site infection.
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reported as an outcome;2)all patients included had“dirty”surgi-cal procedures(except for Q2addressing the u of aqueous iodo-phor irrigation);3)the study only included oral or dental health procedures;4)the surgical procedures did not include primary closure of the incision in the operating room(eg,orthopedic pin sites,thoracotomies,or percutaneous endoscopic gastrostomy [PEG]procedures,or wounds healing by condary intention);or 5)the study evaluated wound protectors ud postincision. Evidence-bad recommendations in this guideline were cross-checked with tho from other guidelines identified in a system-atic arch.
黄脸婆怎么变白CDC completed a draft of the guideline and shared it with the expert panel for in-depth review and then with HICPAC and mem-bers of the public at committee meetings(June2010to July2015). CDC posted notice in the Federal Register for the following2peri-ods of public comment:from January29to February28,2014,and from April8to May8,2014.Comments were aggregated and re-viewedwiththewritinggroupandatanotherHICPACmeeting.Bad on the comments received,the literature arch was updated,and new data were incorporated into a revid draft.Further input was provided by HICPAC during a public teleconference in May2015.Fi-nalHICPACinputwasprovidedviaavotebymajorityruleinJuly2015. After final HICPAC input,CDC updated the draft document and obtained final CDC clearance and coauthor approval.
Recommendation Categories
天下水
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 mod-erate–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,aptic technique)supported by low to very low–quality evidence.
•Category IC:A strong recommendation required by state or fed-eral regulation.
•Category II:A weak recommendation supported by any quality evidence suggesting a trade-off between clinical benefits and harms.
•No recommendation/unresolved issue:An issue for which there is low to very low–quality evidence with uncertain trade-offs be-tween the benefits and harms or no published evidence on out-comes deemed critical to weighing the risks and benefits of a given intervention.
Recommendations
Core Section
In2006,approximately80million surgical procedures were per-formed in the United States at inpatient hospitals(46million)7and ambulatory hospital–affiliated or freestanding(32million)ttings.6 Between2006and2009,SSIs complicated approximately1.9%of surgical procedures in the United States.19However,the number of SSIs is likely to be underestimated given that approximately50% of SSIs become evident after discharge.20Estimated mean attrib-utablecostsofSSIsrangefrom$10443in2005USdollarsto$25546 in2002US dollars per infection.3-5,11Costs can exceed$90000per infection when the SSI involves a prosthetic joint implant21,22or an antimicrobial-resistant organism.23The Core Section of this guide-line(eAppendix1of the Supple
ment)includes recommendations for the prevention of SSI that are generalizable across surgical proce-dures,with some exceptions as mentioned below.
Parenteral Antimicrobial Prophylaxis
1A.1.Administer preoperative antimicrobial agents only when indi-cated bad on published clinical practice guidelines and timed such that a bactericidal concentration of the agents is established in the rum and tissues when the incision is made.(Category IB–strong recommendation;accepted practice.)
1A.2.No further refinement of timing can be made for preoperative antimicrobial agents bad on clinical outcomes.(No recommenda-tion/unresolved issue.)
1B.Administer the appropriate parenteral prophylactic antimicro-bial agents before skin incision in all cesarean ction procedures. (Category IA–strong recommendation;high-quality evidence.)
购置税优惠政策1C.The literature arch did not identify randomized controlled trials that evaluated the benefits and harms of weight-adjusted paren-teral antimicrobial prophylaxis dosing and its effect on the risk of SSI.Other organizations have made recommendations bad on ob-rvational and pharmacokinetic
data,and a summary of the rec-ommendations can be found in the Other Guidelines ction of the narrative summary for this question(eAppendix1of the Supple-ment).(No recommendation/unresolved issue.)
1D.The arch did not identify sufficient randomized controlled trial evidence to evaluate the benefits and harms of intraoperative re-dosing of parenteral prophylactic antimicrobial agents for the pre-vention of SSI.Other organizations have made recommendations bad on obrvational and pharmacokinetic data,and a summary of the recommendations can be found in the Other Guidelines c-tion of the narrative summary for this question(eAppendix1of the Supplement).(No recommendation/unresolved issue.)
1E.In clean and clean-contaminated procedures,do not administer additional prophylactic antimicrobial agent dos after the surgical incision is clod in the operating room,even in the prence of a drain.(Category IA–strong recommendation;high-quality evidence.)
Nonparenteral Antimicrobial Prophylaxis
2A.1.Randomized controlled trial evidence suggested uncertain trade-offs between the benefits and harms regarding intraopera-tive antimicrobial irrigation(eg,intra-abdominal,deep,or subcuta-neous tis
sues)for the prevention of SSI.Other organizations have made recommendations bad on the existing evidence,and a sum-mary of the recommendations can be found in the Other Guide-lines ction of the narrative summary for this question(eAppen-dix1of the Supplement).(No recommendation/unresolved issue.)
2A.2.The arch did not identify randomized controlled trials that evaluated soaking prosthetic devices in antimicrobial solutions be-fore implantation for the prevention of SSI.(No recommendation/ unresolved issue.)
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2B.1.Do not apply antimicrobial agents(ie,ointments,solutions,or powders)to the surgical incision for the prevention of SSI.(Cat-egory IB–strong recommendation;low-quality evidence.)
2B.2.Application of autologous platelet-rich plasma is not neces-sary for the prevention of SSI.(Cate
gory II–weak recommendation; moderate-quality evidence suggesting a trade-off between clinical benefits and harms.)
2C.Consider the u of triclosan-coated sutures for the prevention of SSI.(Category II–weak recommendation;moderate-quality evi-dence suggesting a trade-off between clinical benefits and harms.)
2D.Randomizedcontrolledtrialevidencesuggesteduncertaintrade-offs between the benefits and harms regarding antimicrobial dress-ings applied to surgical incisions after primary closure in the oper-ating room for the prevention of SSI.(No recommendation/ unresolved issue.)
Glycemic Control
3A.1.Implement perioperative glycemic control and u blood glu-co target levels less than200mg/dL in patients with and with-out diabetes.(Category IA–strong recommendation;high to mod-erate–quality evidence.)
3A.2.The arch did not identify randomized controlled trials that evaluated lower(<200mg/dL)or narrower blood gluco target lev-els than recommended in this guideline nor the optimal timing,du-r
ation,or delivery method of perioperative glycemic control for the prevention of SSI.Other organizations have made recommenda-tions bad on obrvational evidence,and a summary of the rec-ommendations can be found in the Other Guidelines ction of the narrative summary for this question(eAppendix1of the Supple-ment).(No recommendation/unresolved issue.)
3B.The arch did not identify randomized controlled trials that evaluated the optimal hemoglobin A1C target levels for the preven-tion of SSI in patients with and without diabetes.(No recommen-dation/unresolved issue.)
Normothermia
4.Maintain perioperative normothermia.(Category IA–strong rec-ommendation;high to moderate–quality evidence.)
5.The arch 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.Other organizations have made recommendations bad on obrvational evidence,and a summary of the recommendations can be found in the Other Guidelines ction of the narrative summary for this question (eAppendix1of the Supplement).(No re
commendation/ unresolved issue.)
Oxygenation
6A.Randomizedcontrolledtrialevidencesuggesteduncertaintrade-offs between the benefits and harms regarding the administration of incread fraction of inspired oxygen(F IO
2
)via endotracheal in-tubation during only the intraoperative period in patients with nor-mal pulmonary function undergoing general anesthesia for the pre-vention of SSI.(No recommendation/unresolved issue.)6B.For patients with normal pulmonary function undergoing gen-
eral anesthesia with endotracheal intubation,administer incread F IO
2
during surgery and after extubation in the immediate postop-erative period.To optimize tissue oxygen delivery,maintain peri-operative normothermia and adequate volume replacement.(Cat-egory IA–strong recommendation;moderate-quality evidence.)
6C.Randomizedcontrolledtrialevidencesuggesteduncertaintrade-offs between the benefits and harms regarding the administration
of incread F IO
2
via face mask during the perioperative period in patients with normal pulmonary function undergoing general an-esthesia without endotracheal intubation or neuraxial anesthesia(ie, spinal,epidural,or local nerve blocks)for the prevention of SSI.(No recommendation/unresolved issue.)
6D.Randomized controlled trial evidence suggested uncertain trade-offs between the benefits and harms regarding the admin-
istration of incread F IO
2
via face mask or nasal cannula during only the postoperative period in patients with normal pulmonary function for the prevention of SSI.(No recommendation/ unresolved issue.)
7.The arch did not identify randomized controlled trials that evalu-
ated the optimal target level,duration,and delivery method of F IO
2 for the prevention of SSI.Other organizations have made recom-mendations bad on obrvational studies,and a summary of the recommendations can be found in the Other Guidelines ction of the narrative summary for this question(eAppendix1of the Supple-ment).(No recommendation/unresolved issue.)
Antiptic Prophylaxis
8A.1.Advi patients to shower or bathe(full body)with soap(an-timicrobial or nonantimicrobial)or an antiptic agent on at least the night before the operative day.(Category IB–strong recommenda-tion;accepted practice.)
8A.2.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 antiptic agent applications,or the u of chlorhexidine glu-conate washcloths for the prevention of SSI.(No recommendation/ unresolved issue.)
8B.Perform intraoperative skin preparation with an alcohol-bad antiptic agent unless contraindicated.(Category IA–strong rec-ommendation;high-quality evidence.)
8C.Application of a microbial alant immediately after intraopera-tive skin preparation is not necessary for the prevention of SSI.(Cat-egory II–weak recommendation;low-quality evidence suggesting a trade-off between clinical benefits and harms.)
8D.The u of plastic adhesive drapes with or without antimicro-bial properties is not necessary for the prevention of SSI.(Category II–weak recommendation;high to moderate–quality evidence sug-gesting a trade-off between clinical benefits and harms.)
9A.Consider intraoperative irrigation of deep or subcutaneous tis-sues with aqueous iodophor solution for the prevention of SSI.In-traperitoneal lavage with aqueous iodophor solution in contami-nated or dirty abdominal procedures is not necessary.(Category II–weak recommendation;moderate-quality evidence suggesting a trade-off between clinical benefits and harms.)
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9B.The arch did not identify randomized controlled trials that evaluated soaking prosthetic devices in antiptic solutions before implantation for the prevention of SSI.(No recommendation/ unresolved issue.)
10.Randomized controlled trial evidence was insufficient to evalu-ate the trade-offs between the benefits and harms of repeat appli-cation of antiptic agents to the patient’s skin immediately before closing the surgical incision for the prevention of SSI.(No recommendation/unresolved issue.)
Prosthetic Joint Arthroplasty Section
Preventioneffortsshouldtargetallsurgicalproceduresbutespecially tho in which the human and financial burden is greatest.In2011, primary total knee arthroplasty accounted for more than half of the 1.2million prosthetic joint arthroplasty procedures(primary and re-vision)performed in the United States,followed by total hip arthro-plastyandhiphemiarthroplasty.24Primaryshoulder,elbow,andankle arthroplasties are much less common.By2030,prosthetic joint ar-throplasties are projected to increa to3.8million procedures per year.25-27wps怎么求和
Infection is the most common indication for revision in total knee arthroplasty28and the third most common indication in total hip arthroplasty.28By2030,the infection risk for hip and knee arthroplasty is expected to increa from2.18%22to6.5% and6.8%,respectively.25In addition,owing to increasing risk and the number of individuals undergoing prosthetic joint arthro-plasty procedures,the total number of hip and knee prosthetic joint infections is projected to increa to221500cas per year by2030,at a cost of more than$1.62billion.22,25The Prosthetic Joint Arthroplasty ction contains recommendations that are applicable to the procedures(eAppendix1of the Supplement).
Blood Transfusion
手机屏幕图片11A.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 rec-ommendations on this topic,and a reference to the recommen-dations can be found in the Other Guidelines ction of the narra-tive summary for this question(eAppendix1of the Supplement). (No recommendation/unresolved issue.)
11B.Do not withhold transfusion of necessary blood products from surgical patients as a means to prevent SSI.(Category IB–strong recommendation;accepted practice.)
Systemic Immunosuppressive Therapy
12and13.Available evidence suggested uncertain trade-offs between the benefits and harms of systemic corticosteroid or other immunosuppressive therapies on the risk of SSI in pros-thetic joint arthroplasty.Other organizations have made recom-mendations bad on the existing evidence,and a summary of the recommendations can be found in the Other Guidelines ction of the narrative summary for this question(eAppendix1of the Supplement).(No recommendation/unresolved issue.)14.For prosthetic joint arthroplasty patients receiving systemic corticosteroid or other immunosuppressive therapy,recommen-dation1E applies:in clean and clean-contaminated procedures, do not administer additional antimicrobial prophylaxis dos after the surgical incision is clod in the operating room,even in the prence of a drain.(Category IA–strong recommendation;high-quality evidence.)
Intra-articular Corticosteroid Injection
15and16.Available evidence suggested uncertain trade-offs between the benefits and harms of the u and timing of preop-erative intra-articular corticosteroid injection on the incidence of SSI in prosthetic joint arthroplasty.Other organizations have made recommendations bad on obrvation
al studies,and a summary of the recommendations can be found in the Other Guidelines ction of the narrative summary for this ques-tion(eAppendix1of the Supplement).(No recommendation/ unresolved issue.)
Anticoagulation
17.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 bad on the existing evidence,and the references can be found in the Other Guide-lines ction of the narrative summary for this question(eAppen-dix1of the Supplement).(No recommendation/unresolved issue.)
Orthopedic Surgical Space Suit
18.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.(No recommendation/unresolved issue.)
Postoperative Antimicrobial Prophylaxis Duration
With Drain U
微妙的意思19.In prosthetic joint arthroplasty,recommendation1E applies:in clean and clean-contaminated procedures,do not administer addi-tional antimicrobial prophylaxis dos after the surgical incision is clod in the operating room,even in the prence of a drain.(Cat-egory IA–strong recommendation;high-quality evidence.)
Biofilm
20A.Availableevidencesuggesteduncertaintrade-offsbetweenthe benefits and harms regarding cement modifications and the pre-vention of biofilm formation or SSI in prosthetic joint arthroplasty. (No recommendation/unresolved issue.)
20B.The arch did not identify studies evaluating prosthesis modi-fications for the prevention of biofilm formation or SSI in prosthetic joint arthroplasty.(No recommendation/unresolved issue.)
20C.The arch did not identify studies evaluating vaccines for the prevention of biofilm formation or SSI in prosthetic joint arthro-plasty.(No recommendation/unresolved issue.)
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