Abstract
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Imperceptibly, the operation seemed over before it had even begun. As we completed the axillary dissection and prepared to place the Jackson-Pratt drain, my anxiety returned as I began to try to piece together what had just happened in order to dictate the case. As I recollected the events of the preceding hour, I rapidly wrote down on paper the post-operative orders for the patient who would spend the next week in the hospital getting intravenous cefazolin while we waited for output from her drain to decrease.
Since that fateful day in July 1991, I have since differentiated into a trauma and critical care surgeon. The principles of anatomy, surgical technique, elimination of dead space, and meticulous hemostasis are lessons that I still apply to every operation. In fact, modified radical mastectomies have become an uncommon operation as nipple-sparing mastectomies, breast-conserving operations, and sentinel lymph node biopsies have largely replaced more cosmetically invasive procedures. These significant changes in surgical practice have been paralleled by radical changes in how we train surgical residents and how surgeons' skills are judged; we are graded by many external groups including the Centers for Medicare and Medicaid Services, third party payers, and consumer report cards based on many factors, including patient outcomes and costs.
Given the extent of the changes in surgical care over the past 25 years, it is important to take note of the recent publication of the U.S. Centers for Disease Control and Prevention's (CDC) “Guideline for the Prevention of Surgical Site Infection (SSI),” updating the previous version that was published in 1999.
The Guideline for the Prevention of SSI is divided into a core section that includes recommendations generalizable across surgical specialties and a second section that addresses prevention of SSI after prosthetic joint arthroplasty. When successfully implemented, these guidelines are intended to decrease the occurrence of surgical infections and reduce costs related to complications and unnecessary utilization. The majority of the writing group for this guideline consisted of surgeons who represented a number of professional societies. Although I did not participate in the writing group, I am a member of the Healthcare Infection Control Practices Advisory Committee (HICPAC), the federal advisory group that provided input to the CDC for this guideline. Participating in the HICPAC discussions around this guideline has given me insight into both the strengths and the limitations of the guideline-writing process.
To supplement the guidelines published in the Journal of the American Medical Association [1], four complementary articles are printed in this issue of Surgical Infections. The article by Solomkin et al. (this issue) provides an overview of the history of the guideline development, reviews the methodology of modified Grading of Recommendations Assessment, Development, and Evaluation (GRADE), epidemiology, pathogenesis, and microbiology of SSI. Itani et al. (this issue) have provided insight into future research directions to continue progress in the prevention of SSI. Segreti et al. (this issue) delve deeper into the process for the guideline development related to prosthetic joint arthroplasty, including epidemiology, pathogenesis, microbiology, and prevention. Finally, Berbari et al. (this issue) conclude with the challenge of future research opportunities in peri-prosthetic joint infection prevention based on guideline evidence gaps and subject matter experts.
When reviewing the updated guidelines, some important new recommendations were made that may be departures from the current practice of some surgeons. These include pre-operative skin preparation with an alcohol-based antiseptic agent and avoiding additional doses of prophylactic antimicrobial agents after the surgical incision is closed in the operating room, even when a drain is left in place. Back in the days of my training, those actions would have been anathema and would have led to stern reprimands by my chief residents.
Despite these important additions, guidance around a number of topics that are of practical importance to surgeons is absent from these updated recommendations for several reasons. First, there are practices that surgeons instinctively understand to be important but are unlikely to be evaluated through research. As one example, the importance of surgical technique cannot be overemphasized. Skilled surgeons who are technically adept, minimize devitalized tissue, close dead space, and operate efficiently will have fewer infectious complications. How does one collect evidence on these aspects of surgical technique? We will never have randomized controlled trials (RCTs) comparing the infectious outcomes of poorly skilled surgeons versus master surgeons. All surgeons know that technique matters. A primary total knee arthroplasty that takes longer than usual is typically a marker of a more complicated patient, relatively inexpert surgical technique, or a combination of both. Often, infectious complications develop in these patients. Surgery is very unforgiving.
Second, the standards imposed by the CDC and HICPAC guideline process excluded some potentially useful scientific evidence from consideration. At the outset of the SSI guideline revision process, the decision was made to use an adapted GRADE system to weigh the strength of the evidence. Well-conducted RCTs represent the highest level of evidence. The absence of robust literature made it challenging to formulate recommendations in many areas. For example, there is no recommendation provided for antibiotic re-dosing during long procedures or use of weight-based antibiotic dosing because of the absence of RCTs on this topic. For prosthetic joint arthroplasty, even with inclusion of non-RCT data, there were no recommendations regarding the use of orthopedic space suits or cement modifications to prevent biofilm formation because of the paucity of high-quality studies evaluating the impact of these practices.
Despite these limitations, implementing what we do know is vital to decrease SSI morbidity and death. Some practices are considered to be standard of care for SSI prevention and, because of this, are unlikely to be assessed by future research. For this reason, several of these practices have been brought forward from the 1999 guideline and included as an appendix within the updated guideline despite a relative absence of high-quality supporting evidence.
Research is desperately needed to evaluate many other important topics. Surgeons should partner with infection preventionists and healthcare epidemiologists to design adequately powered studies that assess the impact of specific interventions on SSI risk using thoughtful, scientifically sound research methods that are adequately powered to answer the study question.
Importantly, these updated SSI recommendations provide an excellent starting point for multi-disciplinary professional societies to build on to create additional expert guidance around practical and important questions for which there is a paucity of high-level evidence.
Finally, guidelines are simply signposts to lead the way forward. Without effective implementation, any guideline will have limited impact on the patients that we serve. Through partnerships with surgeons, anesthesiologists, peri-operative nurses, physician assistants, allied peri-operative assistive personnel, infection prevention staff, healthcare epidemiologists, healthcare administrators, and other stakeholders, we can create systems within our healthcare facilities that ensure consistent implementation of best practices to optimize our ability to provide safe, high quality peri-operative care. “Cut, cut, cut…” still echoes in my ears as I reflect on my first major case as a surgeon. When I teach my surgical residents, I wonder what they will remember about my exhortations.