Infectious Disease

Stop antibiotics once incisions are closed, updated SSI guidance says

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Disclosures:
Calderwood reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

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Key takeaways:

  • Surgical site infections occur in 1% to 3% of patients undergoing inpatient surgery.
  • There is no evidence that continuing antibiotics after a patient’s incision has been closed prevents these infections.

Antibiotics administered before and during surgery should be stopped immediately after the patient’s incision is closed, according to updated recommendations for preventing surgical site infections.

Surgical site infections (SSIs) are among the most common and costly health care-associated infections, occurring in approximately 1% to 3% of patients undergoing inpatient surgery, according to Michael S Calderwood, MD, MPH, FIDSA, chief quality officer at Dartmouth Hitchcock Medical Center and associate professor of medicine at the Geisel School of Medicine at Dartmouth.

IDN0523Calderwood_Graphic_01_WEB

Calderwood MS, et al. Infect Control Hosp Epidemic. 2023;doi:10.1017/ice.2023.67.

These patients, he explained, are up to 11 times more likely to die compared with patients without SSIs despite up to 60% of SSIs being preventable using evidence-based guidelines.

“After a thorough review of thousands of articles published since 2014, we have updated recommendations for prevention practices aimed at improving care outcomes for patients undergoing surgical procedures,” Calderwood told Healio.

Michael S Calderwood

Discontinuing antibiotics given before and during surgery was one of the key updates, according to Calderwood.

He explained that they found no evidence that continuing antibiotics after a patient’s incision has been closed prevents SSIs, although continuing antibiotics does increase the patient’s risk of Clostridioides difficile infection, acute kidney injury and antimicrobial resistance.

This was just one of many updates suggested by Calderwood and colleagues in the new guidance recently published in Infection Control & Hospital Epidemiology.

“Our hope is that hospitals and health care teams will review the updated guidelines for support of current prevention practices and adoption of new standards targeted at our high reliability goal of zero harm,” Calderwood said.

Other preoperative, intraoperative and postoperative guidance updates outlined in the update include:

  1. obtaining a full allergy history from patients who self-report penicillin allergy because many patients with a self-reported penicillin allergy can safely receive cefazolin rather than alternate antibiotics that are less effective against surgical infections;
  2. using antimicrobial prophylaxis before elective colorectal surgery antibiotics rather than mechanical bowel preparation;
  3. using antiseptic-containing preoperative vaginal preparation agents to reduce the risk of endometritis for patients undergoing cesarean delivery or hysterectomy;
  4. reserving vancomycin for specific situations, such as a patient who is known to be colonized with MRSA, particularly if the surgery involves prosthetic material, and in proven MRSA outbreaks;
  5. decolonizing patients with an antistaphylococcal agent in the preoperative setting for high-risk procedures, especially orthopedic and cardiothoracic surgeries;
  6. monitoring and maintaining postoperative blood glucose levels between 110 and 150 mg/dL for patients with an elevated blood glucose level, regardless of diabetes status because higher glucose levels in the postoperative setting are associated with higher infection rates;
  7. considering the use of negative-pressure dressings, especially for abdominal surgery or joint arthroplasty patients because evidence has shown these dressings reduce SSIs in certain patients.

“Health care facilities should have multidisciplinary teams focused on perioperative care review these guidelines to ensure that health care personnel know, utilize, and educate others on evidence-based prevention practices,” Calderwood said. “This includes performing direct observation audits of operating room, perioperative, and central sterile reprocessing processes and practices.”

He added that these teams and these observations can then “target the creation or updating of prevention bundles, with ongoing feedback to surgical and perioperative personnel and leadership about opportunities that exist.”

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