美国CDC手术部位感染预防指南(2017) | 中国病理生理学会危重病医学专业委员会
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美国CDC手术部位感染预防指南(2017)
2017年08月25日 指南导读, 进展交流 暂无评论

Special Communication

May 3, 2017

Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017

Sandra I. Berríos-Torres, Craig A. Umscheid, Dale W. Bratzler, DO, et al.

JAMA Surg. Published online May 3, 2017. doi:10.1001/jamasurg.2017.0904

Recommendations

Core Section

Parenteral Antimicrobial Prophylaxis

1A.1. Administer preoperative antimicrobial agents only when indicated based on published clinical practice guidelines and timed such that a bactericidal concentration of the agents is established in the serum and tissues when the incision is made. (Category IB–strong recommendation; accepted practice.)

 

1A.2. No further refinement of timing can be made for preoperative antimicrobial agents based on clinical outcomes. (No recommendation/unresolved issue.)

 

1B. Administer the appropriate parenteral prophylactic antimicrobial agents before skin incision in all cesarean section procedures. (Category IA–strong recommendation; high-quality evidence.)

 

1C. The literature search did not identify randomized controlled trials that evaluated the benefits and harms of weight-adjusted parenteral antimicrobial prophylaxis dosing and its effect on the risk of SSI. Other organizations have made recommendations based on observational and pharmacokinetic data, and a summary of these recommendations can be found in the Other Guidelines section of the narrative summary for this question (eAppendix 1 of the Supplement). (No recommendation/unresolved issue.)

 

1D. The search did not identify sufficient randomized controlled trial evidence to evaluate the benefits and harms of intraoperative redosing of parenteral prophylactic antimicrobial agents for the prevention of SSI. Other organizations have made recommendations based on observational and pharmacokinetic data, and a summary of these recommendations can be found in the Other Guidelines section of the narrative summary for this question (eAppendix 1 of the Supplement). (No recommendation/unresolved issue.)

1E. In clean and clean-contaminated procedures, do not administer additional prophylactic antimicrobial agent doses after the surgical incision is closed in the operating room, even in the presence of a drain. (Category IA–strong recommendation; high-quality evidence.)

Nonparenteral Antimicrobial Prophylaxis

2A.1. Randomized controlled trial evidence suggested uncertain trade-offs between the benefits and harms regarding intraoperative antimicrobial irrigation (eg, intra-abdominal, deep, or subcutaneous tissues) for the prevention of SSI. Other organizations have made recommendations based on the existing evidence, and a summary of these recommendations can be found in the Other Guidelines section of the narrative summary for this question (eAppendix 1 of the Supplement). (No recommendation/unresolved issue.)

2A.2. The search did not identify randomized controlled trials that evaluated soaking prosthetic devices in antimicrobial solutions before implantation for the prevention of SSI. (No recommendation/unresolved issue.)

2B.1. Do not apply antimicrobial agents (ie, ointments, solutions, or powders) to the surgical incision for the prevention of SSI. (Category IB–strong recommendation; low-quality evidence.)

 

2B.2. Application of autologous platelet-rich plasma is not necessary for the prevention of SSI. (Category II–weak recommendation; moderate-quality evidence suggesting a trade-off between clinical benefits and harms.)

 

2C. Consider the use of triclosan-coated sutures for the prevention of SSI. (Category II–weak recommendation; moderate-quality evidence suggesting a trade-off between clinical benefits and harms.)

 

2D. Randomized controlled trial evidence suggested uncertain trade-offs between the benefits and harms regarding antimicrobial dressings applied to surgical incisions after primary closure in the operating room for the prevention of SSI. (No recommendation/unresolved issue.)

Glycemic Control

3A.1. Implement perioperative glycemic control and use blood glucose target levels less than 200 mg/dL in patients with and without diabetes. (Category IA–strong recommendation; high to moderate–quality evidence.)

3A.2. The search did not identify randomized controlled trials that evaluated lower (<200 mg/dL) or narrower blood glucose target levels than recommended in this guideline nor the optimal timing, duration, or delivery method of perioperative glycemic control for the prevention of SSI. Other organizations have made recommendations based on observational evidence, and a summary of these recommendations can be found in the Other Guidelines section of the narrative summary for this question (eAppendix 1 of the Supplement). (No recommendation/unresolved issue.)

 

3B. The search did not identify randomized controlled trials that evaluated the optimal hemoglobin A1C target levels for the prevention of SSI in patients with and without diabetes. (No recommendation/unresolved issue.)

Normothermia

4. Maintain perioperative normothermia. (Category IA–strong recommendation; high to moderate–quality evidence.)

5. The search did not identify randomized controlled trials that evaluated strategies to achieve and maintain normothermia, the lower limit of normothermia, or the optimal timing and duration of normothermia for the prevention of SSI. Other organizations have made recommendations based on observational evidence, and a summary of these recommendations can be found in the Other Guidelines section of the narrative summary for this question (eAppendix 1 of the Supplement). (No recommendation/unresolved issue.)

Oxygenation

6A. Randomized controlled trial evidence suggested uncertain trade-offs between the benefits and harms regarding the administration of increased fraction of inspired oxygen (Fio2) via endotracheal intubation during only the intraoperative period in patients with normal pulmonary function undergoing general anesthesia for the prevention of SSI. (No recommendation/unresolved issue.)

 

6B. For patients with normal pulmonary function undergoing general anesthesia with endotracheal intubation, administer increased Fio2 during surgery and after extubation in the immediate postoperative period. To optimize tissue oxygen delivery, maintain perioperative normothermia and adequate volume replacement. (Category IA–strong recommendation; moderate-quality evidence.)

 

6C. Randomized controlled trial evidence suggested uncertain trade-offs between the benefits and harms regarding the administration of increased Fio2via face mask during the perioperative period in patients with normal pulmonary function undergoing general anesthesia without endotracheal intubation or neuraxial anesthesia (ie, spinal, epidural, or local nerve blocks) for the prevention of SSI. (No recommendation/unresolved issue.)

 

6D. Randomized controlled trial evidence suggested uncertain trade-offs between the benefits and harms regarding the administration of increased Fio2via face mask or nasal cannula during only the postoperative period in patients with normal pulmonary function for the prevention of SSI. (No recommendation/unresolved issue.)

 

7. The search did not identify randomized controlled trials that evaluated the optimal target level, duration, and delivery method of Fio2 for the prevention of SSI. Other organizations have made recommendations based on observational studies, and a summary of these recommendations can be found in the Other Guidelines section of the narrative summary for this question (eAppendix 1 of the Supplement). (No recommendation/unresolved issue.)

Antiseptic Prophylaxis

8A.1. Advise patients to shower or bathe (full body) with soap (antimicrobial or nonantimicrobial) or an antiseptic agent on at least the night before the operative day. (Category IB–strong recommendation; accepted practice.)

8A.2. Randomized controlled trial evidence suggested uncertain trade-offs between the benefits and harms regarding the optimal timing of the preoperative shower or bath, the total number of soap or antiseptic agent applications, or the use of chlorhexidine gluconate washcloths for the prevention of SSI. (No recommendation/unresolved issue.)

 

8B. Perform intraoperative skin preparation with an alcohol-based antiseptic agent unless contraindicated. (Category IA–strong recommendation; high-quality evidence.)

 

8C. Application of a microbial sealant immediately after intraoperative skin preparation is not necessary for the prevention of SSI. (Category II–weak recommendation; low-quality evidence suggesting a trade-off between clinical benefits and harms.)

 

8D. The use of plastic adhesive drapes with or without antimicrobial properties is not necessary for the prevention of SSI. (Category II–weak recommendation; high to moderate–quality evidence suggesting a trade-off between clinical benefits and harms.)

 

9A. Consider intraoperative irrigation of deep or subcutaneous tissues with aqueous iodophor solution for the prevention of SSI. Intraperitoneal lavage with aqueous iodophor solution in contaminated or dirty abdominal procedures is not necessary. (Category II–weak recommendation; moderate-quality evidence suggesting a trade-off between clinical benefits and harms.)

 

9B. The search did not identify randomized controlled trials that evaluated soaking prosthetic devices in antiseptic solutions before implantation for the prevention of SSI. (No recommendation/unresolved issue.)

 

10. Randomized controlled trial evidence was insufficient to evaluate the trade-offs between the benefits and harms of repeat application of antiseptic agents to the patient’s skin immediately before closing the surgical incision for the prevention of SSI. (No recommendation/unresolved issue.)

Prosthetic Joint Arthroplasty Section

Blood Transfusion

11A. Available evidence suggested uncertain trade-offs between the benefits and harms of blood transfusions on the risk of SSI in prosthetic joint arthroplasty. Other organizations have made recommendations on this topic, and a reference to these recommendations can be found in the Other Guidelines section of the narrative summary for this question (eAppendix 1 of the Supplement). (No recommendation/unresolved issue.)

 

11B. Do not withhold transfusion of necessary blood products from surgical patients as a means to prevent SSI. (Category IB–strong recommendation; accepted practice.)

Systemic Immunosuppressive Therapy

12 and 13. Available evidence suggested uncertain trade-offs between the benefits and harms of systemic corticosteroid or other immunosuppressive therapies on the risk of SSI in prosthetic joint arthroplasty. Other organizations have made recommendations based on the existing evidence, and a summary of these recommendations can be found in the Other Guidelines section of the narrative summary for this question (eAppendix 1 of the Supplement). (No recommendation/unresolved issue.)

 

14. For prosthetic joint arthroplasty patients receiving systemic corticosteroid or other immunosuppressive therapy, recommendation 1E applies: in clean and clean-contaminated procedures, do not administer additional antimicrobial prophylaxis doses after the surgical incision is closed in the operating room, even in the presence of a drain. (Category IA–strong recommendation; high-quality evidence.)

Intra-articular Corticosteroid Injection

15 and 16. Available evidence suggested uncertain trade-offs between the benefits and harms of the use and timing of preoperative intra-articular corticosteroid injection on the incidence of SSI in prosthetic joint arthroplasty. Other organizations have made recommendations based on observational studies, and a summary of these recommendations can be found in the Other Guidelines section of the narrative summary for this question (eAppendix 1 of the Supplement). (No recommendation/unresolved issue.)

Anticoagulation

17. Available evidence suggested uncertain trade-offs between the benefits and harms of venous thromboembolism prophylaxis on the incidence of SSI in prosthetic joint arthroplasty. Other organizations have made recommendations based on the existing evidence, and these references can be found in the Other Guidelines section of the narrative summary for this question (eAppendix 1 of the Supplement). (No recommendation/unresolved issue.)

Orthopedic Surgical Space Suit

18. Available evidence suggested uncertain trade-offs between the benefits and harms of orthopedic space suits or the health care personnel who should wear them for the prevention of SSI in prosthetic joint arthroplasty. (No recommendation/unresolved issue.)

Postoperative Antimicrobial Prophylaxis Duration With Drain Use

19. In prosthetic joint arthroplasty, recommendation 1E applies: in clean and clean-contaminated procedures, do not administer additional antimicrobial prophylaxis doses after the surgical incision is closed in the operating room, even in the presence of a drain. (Category IA–strong recommendation; high-quality evidence.)

Biofilm

20A. Available evidence suggested uncertain trade-offs between the benefits and harms regarding cement modifications and the prevention of biofilm formation or SSI in prosthetic joint arthroplasty. (No recommendation/unresolved issue.)

20B. The search did not identify studies evaluating prosthesis modifications for the prevention of biofilm formation or SSI in prosthetic joint arthroplasty. (No recommendation/unresolved issue.)

20C. The search did not identify studies evaluating vaccines for the prevention of biofilm formation or SSI in prosthetic joint arthroplasty. (No recommendation/unresolved issue.)

20D. The search did not identify studies evaluating biofilm control agents, such as biofilm dispersants, quorum sensing inhibitors, or novel antimicrobial agents, for the prevention of biofilm formation or SSI in prosthetic joint arthroplasty. (No recommendation/unresolved issue.)

 

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