Executive Summary of the American College of Surgeons/Surgical Infection Society Surgical Site Infection Guidelines—2016 Update

Overview

Guidelines for the prevention, detection, and management of surgical site infections (SSIs) have been published previously [1–3]. The American College of Surgeons (ACS)/Surgical Infection Society (SIS) SSI Guidelines—2016 Update covers recommended practices in the pre-hospital, hospital, and post-discharge settings. The pre-hospital interventions reviewed are bathing, smoking cessation, long-term glucose control, screening for methicillin-resistant Staphylococcus aureus (MRSA), and bowel preparation for elective colorectal surgery (Table 1). Hospital interventions are peri-operative glucose control, hair removal and skin preparation, surgical hand scrub, surgical attire, antibiotic prophylaxis, intra-operative normothermia, the use of wound protectors and antibiotic sutures, glove and instrument change prior to closure in colorectal surgery, wound closure techniques, topical antibiotic use and wound care, as well as the use of supplemental oxygen. Post-discharge incision care and SSI surveillance are discussed, with the note that no specific practices have been recommended by all groups for these purposes.

Key Updates

Updated literature in several areas led to important new recommendations in the 2016 guidelines. These topics include blood glucose control in the peri-operative period and the optimal duration of prophylactic antibiotic administration. Additional topics that warranted exploration were the use of “bundled” care, including pre-operative decolonization protocols for S. aureus and SSI prevention bundles in the field of colorectal surgery. Finally, we addressed the topic of surgical attire, which remains an area of controversy in the absence of high-quality evidence to guide recommendations.

The importance of peri-operative blood glucose control for diabetic patients has been established previously. Recent literature exploring the importance of long-term blood glucose control found that when the peri-operative blood glucose concentration is controlled, long-term glucose control (measured by hemoglobin A1C) is not associated with SSI [4,5]. In other words, peri-operative blood glucose control in diabetic patients is a more important determinant of SSI risk than is long-term control. Additional literature has demonstrated that peri-operative blood glucose control reduces SSI risk in non-diabetic as well as diabetic patients [6,7]. The 2016 Update recommends target peri-operative blood glucose concentrations between 110–150 mg/dL in all patients, regardless of diabetic status, except in cardiac surgery patients, in whom the target peri-operative blood glucose concentration is <180 mg/dL.

Prior guidelines supported timely cessation of prophylactic antibiotics within the 24 h after incision closure, with the exception of cardiac surgery, where the acceptable duration was longer. Numerous studies have shown no reduction in SSI risk with administration of prophylactic antibiotics beyond incision closure [1,2,8]. Further, prolonged administration of antibiotics increases the risk of symptomatic Clostridium difficile infection [9]. For this reason, the 2016 Update recommends cessation of prophylactic antibiotics at the time of incision closure with some exceptions (Table 2).

Considerable recent literature has examined the efficacy of care bundles for purposes including pre-operative S. aureus decolonization and the prevention of SSI in colorectal surgery. Studies on the benefits of care bundles have yielded mixed results [10–12], but one key finding has been that the existence of a bundle does not ensure bundle compliance. In studies with high compliance on the part of both patients and providers, bundles appear to provide substantial benefit [13]. As we move toward increasing standardization of care, it is important to emphasize that achieving high compliance rates and “buy-in” are key to the success of bundled interventions.

Finally, the ACS/SIS Guidelines—2016 Update addresses the continuing controversy around surgical attire, an area where there is a paucity of data to guide evidence-based practice recommendations. In the absence of high-quality, robust data, different organizations have endorsed different guidelines. Most organizations recommend practices such as limitation of scrub garb to the hospital setting, changing visibly soiled scrub garments between cases, and wearing professional attire (not scrubs) whenever possible outside the operating room. There are no data in the literature examining cloth vs. disposable scrub hats despite the controversy this topic has sparked, and there have been no comparisons of skullcaps vs. bouffants and SSI. Current Association of periOperative Registered Nurses (AORN) and Joint Commission guidelines support bouffant use alone [14], whereas the ACS surgical attire policy supports skullcap use if nearly all of the hair is covered by the cap, with only a limited amount of hair exposed at the nape of the neck and at the sideburns [15].

Moving forward, many areas will benefit from further research to guide recommended practices, including exceptions to more broad antibiotic prophylaxis guidelines, the use of topical and local antibiotics, and post-operative incision management and SSI surveillance. Additionally, there may be value in the development of a national consensus regarding SSI guidelines supported by organizations representing multiple specialties to clarify the best practices for providers in the field of surgery.