New guidance: antibiotics should be halted upon closure of incisions

ARLINGTON, Va. (May 4, 2023) — Antibiotics administered before and during surgery should be discontinued immediately after a patient’s incision is closed, according to updated recommendations for preventing surgical site infections. Experts found no evidence that continuing antibiotics after a patient’s incision has been closed, even if it has drains, prevents surgical site infections. Continuing antibiotics does increase the patient’s risk of C. difficile infection, which causes severe diarrhea, and antimicrobial resistance.

Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2022 Update, published in the journal Infection Control and Healthcare Epidemiology, provides evidence-based strategies for preventing infections for all types of surgeries from top experts from five medical organizations led by the Society for Healthcare Epidemiology of America.

“Many surgical site infections are preventable,” said Michael S. Calderwood, MD, MPH, lead author on the updated guidelines and Chief Quality Officer at Dartmouth Hitchcock Medical Center in Lebanon, New Hampshire. “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.”

Surgical site infections are among the most common and costly healthcare-associated infections, occurring in approximately 1% to 3% of patients undergoing inpatient surgery. Patients with surgical site infections are up to 11 times more likely to die compared to patients without such infections.

Other recommendations:

• Obtain a full allergy history from patients who self-report penicillin allergy. Many patients with a self-reported penicillin allergy can safely receive cefazolin, a cousin to penicillin, rather than alternate antibiotics that are less effective against surgical infections.
• For high-risk procedures, especially orthopedic and cardiothoracic surgeries, decolonize patients with an anti-staphylococcal agent in the pre-operative setting. Decolonization, which was elevated to an essential practice in this guidance, can reduce post-operative S. aureus infections.
• For patients with an elevated blood glucose level, monitor and maintain post-operative blood glucose levels between 110 and 150 mg/dL regardless of diabetes status. Higher glucose levels in the post-operative setting are associated with higher infection rates. However, more intensive post-operative blood glucose control targeting levels below 110 mg/dL has been associated with a risk of significantly lowering the blood glucose level and increasing the risk of stroke or death.
• Use antimicrobial prophylaxis before elective colorectal surgery. Mechanical bowel preparation without use of oral antimicrobial agents has been associated with significantly higher rates of surgical site infection and anastomotic leakage. The use of parenteral and oral antibiotics prior to elective colorectal surgery is now considered an essential practice.
• Consider negative-pressure dressings, especially for abdominal surgery or joint arthroplasty patients. Placing negative-pressure dressings over closed incisions was identified as a new option because evidence has shown these dressings reduce surgical site infections in certain patients. Negative pressure dressings are thought to work by reducing fluid accumulation around the wound.

Additional topics covered in the update include specific risk factors for surgical site infections, surveillance methods, infrastructure requirements, use of antiseptic wound lavage, and sterile reprocessing in the operating room, among other guidance.    

Hospitals may consider these additional approaches when seeking to further improve outcomes after they have fully implemented the list of essential practices. The document classifies tissue oxygenation, antimicrobial powder, and gentamicin-collagen sponges as unresolved issues according to current evidence.  

The document updates the 2014 Strategies to Prevent Surgical Site Infections in Acute Care Hospitals. The Compendium, first published in 2008, is sponsored by the Society for Healthcare Epidemiology (SHEA). It is the product of a collaborative effort led by SHEA, with the Infectious Diseases Society of America, the Association for Professionals in Infection Control and Epidemiology, the American Hospital Association, and The Joint Commission, with major contributions from representatives of several organizations and societies with content expertise. The Compendium is a multiyear, highly collaborative guidance-writing effort by over 100 experts from around the world.

Upcoming Compendium updates will cover strategies to prevent catheter-associated urinary tract infections, methicillin-resistant Staphylococcus aureus infections, and implementation strategies for the prevention of healthcare-associated infections. Strategies for preventing central line-associated bloodstream infections, ventilator and non-ventilator associated pneumonia and events, and C. difficile infections as well as strategies to prevent healthcare-associated infections through hand hygiene were updated recently. Each Compendium article contains infection prevention strategies, performance measures, and approaches to implementation. Compendium recommendations are derived from a synthesis of systematic literature review, evaluation of the evidence, practical and implementation-based considerations, and expert consensus.

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About Infection Control & Hospital Epidemiology
Published through a partnership between the Society for Healthcare Epidemiology of America and Cambridge University Press, Infection Control & Hospital Epidemiology provides original, peer-reviewed scientific articles for anyone involved with an infection control or epidemiology program in a hospital or healthcare facility. ICHE is ranked 24^th out of 94 Infectious Disease Journals in the latest Web of Knowledge Journal Citation Reports from Thomson Reuters.

About the Society for Healthcare Epidemiology of America (SHEA) 

The Society for Healthcare Epidemiology of America (SHEA) is a professional society representing more than 2,000 physicians and other healthcare professionals around the world who possess expertise and passion for healthcare epidemiology, infection prevention, and antimicrobial stewardship. The society’s work improves public health by establishing infection-prevention measures and supporting antibiotic stewardship among healthcare providers, hospitals, and health systems. This is accomplished by leading research studies, translating research into clinical practice, developing evidence-based policies, optimizing antibiotic stewardship, and advancing the field of healthcare epidemiology. SHEA and its members strive to improve patient outcomes and create a safer, healthier future for all. Visit SHEA online at shea-online.org, facebook.com/SHEApreventingHAIs and twitter.com/SHEA_Epi.