Surgical site infections (SSIs) and hospital-acquired infections (HAIs) have become two of the most feared complications associated with the delivery of medical care. The issue of infection has become so important that the American Academy of Orthopaedic Surgeons (AAOS), the Infectious Diseases Society of America (IDSA), the Musculoskeletal Infection Society (MSIS), and numerous other organizations have issued guidelines for the prevention and diagnosis of infection after orthopedic procedures. Similar efforts have taken place in other surgical disciplines.
It is fair to state that the issue of infection after surgical procedures has come to the forefront of all complications and strikes fear in the minds of patients and surgeons who enter the operating room on a daily basis. The immense financial and psychological burden associated with SSIs and HAIs has also prompted regulatory bodies and governmental agencies in the United States and other parts of the world to seek strategies to counter the rising incidence of infection. It is anticipated that “striving for lower incidence of surgical site infection” will be part of the “quality metric” that most payers in the United States, including the Centers for Medicare and Medicaid Services (CMS), will implement in the future. In fact, the incidence of infection after most surgical procedures is tracked carefully by the surveillance arm of the Centers for Disease Control and Prevention (CDC), the National Healthcare Safety Network (NHSN). Most hospitals in the United States are required to report infections occurring after surgical procedures and patient admissions. The CDC has issued specific definitions and reporting instructions for this purpose.
As part of the important mission of reducing the burden of SSIs and HAIs, the CDC has had an active role in producing guidelines for the prevention of SSI. Their latest guidelines, issued in 1999, had relevant and important expert-based recommendations that have certainly served the medical community. The CDC will soon issue their updated guidelines for the prevention of SSI. This time, the CDC has decided to issue evidence-based recommendations. To accomplish this, the CDC convened a large workgroup consisting of experts and representatives of numerous societies, including the AAOS and the MSIS, to evaluate the available literature in issuing these guidelines. The guidelines are divided into 2 sections: the “Core” addresses recommendations applicable across a broad spectrum of surgical procedures, and the new procedure-specific component sections each focus on a single high-volume, high-burden surgical procedure. The first of these component sections focuses on arthroplasty procedures.
One of the sobering discoveries of the workgroup is the fact that there is little evidence to support many of our daily practices applicable to the prevention of infection. Thus, the guidelines, when issued, will reflect the lack of evidence for some of our established and common practices. There will be, however, many other recommendations that are based on available evidence, such as the importance of administration of perioperative antibiotics, to name one. Huge effort has been invested by the CDC and the numerous experts who served in the workgroup to produce these guidelines. The literature has been evaluated extensively. Many conference calls have taken place to discuss the issues, when necessary. In addition, these recommendations have been carefully evaluated by the Healthcare Infection Control Practices Advisory Committee (HICPAC). The guidelines, when issued, will no doubt play a critical role in helping us make strides in reducing the burden of this dreaded complication. The guidelines will also provide a great impetus for the medical community to generate and seek evidence for practices that lack such evidence currently. ◾