As Desiderius Erasmus stated in the 15th century, prevention is better than cure. As the orthopedic community braces itself to deal with the increased burden of infection, prevention of surgical site infection and periprosthetic joint infection has moved into center stage.
The International Consensus on Periprosthetic Joint Infection held a meeting in 2013 and dedicated a workgroup to evaluate the literature and propose recommendations that may be effective in prevention of surgical site infection (SSI). Since then, numerous organizations have addressed this imperative issue and have tried to come up with evidence-based guidelines for the prevention of SSI, of which two notable guidelines were recently released.
Prevention of SSI
On Nov. 3, the WHO, an organization that previously had no full guidelines for SSI prevention, published the first international evidence-based guidelines for SSI prevention. The guidelines include a list of 29 recommendations covering 23 topics. The WHO intends to disseminate these guidelines across the globe in its fight against infection. These guidelines were developed in a relatively short period and may have an immense impact across the world and change some common non-evidence-based practices worldwide.
The CDC is about to publish its new evidence-based guidelines for the prevention of SSI, with a separate section dedicated to the prevention of infection after total joint arthroplasty and acknowledges the gravity of the situation in orthopedic surgery. The CDC guidelines addresses 13 selected fields developed from the previous guidelines, which were developed in 1999, by answering key questions based on the best available evidence.
Due to the lack of evidence in numerous areas, the guidelines by the WHO and CDC fail to be comprehensive.
Many questions regarding common practices, such as methicillin-resistant Staphylococcus aureus screening and decolonization, remain unanswered. However, these guidelines move us toward adapting evidence-based practices that are effective and serve to reduce the economic burden of infection. These guidelines also intend to minimize the liberal use of antimicrobials that contribute toward the emergence of antimicrobial resistance — a true crisis on the rise.
Nonetheless, the administration of antimicrobials continues to be a critical step in SSI prevention. There are recommendations from the American Society of Health System Pharmacists, the Infectious Diseases Society of America, the Surgical Infection Society and the Society for Healthcare Epidemiology of America regarding proper use of antimicrobial agents for SSI prevention.
Outside the United States, the National Institute for Health and Care Excellence guidelines were established based on an extensive literature review and grading of evidence according to its quality. They are composed of concrete statements aimed to help clinicians and patients in decision-making.
These guidelines will serve one important function —to raise awareness about existing issues in the medical community —and may also engender interest leading to the design and execution of studies that will generate data regarding many of our common practices, for which evidence is lacking. What has become clear is the burden of infection and its impact on the society is being felt by all.
- Bratzler DW, et al. Am J Health Syst Pharm. 2013;70: 195-283.
- CDC. Available at: www.cdc.gov/hicpac/pdf/guidelines/SSI_1999.pdf. Accessed: Nov. 9, 2016.
- National Institute for Health and Care Excellence. Available at: www.nice.org.uk/guidance/cg74/history. Accessed: Nov. 9, 2016.
- Parvizi J, et al. Bone Joint J. 2013;95-B: 1450-1452.
- WHO. Available at: http://who.int/gpsc/global-guidelines-web.pdf?ua=1. Accessed: Nov. 9, 2016.
- For more information:
- Javad Parvizi, MD, FRCS, can be reached at The Rothman Institute at Thomas Jefferson University Hospital, Sheridan Building, Suite 1000, 125 S. 9th St., Philadelphia, PA 19107; email: firstname.lastname@example.org.
- Noam Shohat, MD, can be reached at the Department of Orthopedic Surgery, Assaf Harofeh Medical Center, Zerifin, Israel; email: email@example.com.
Disclosures: Parvizi reports he is a consultant to Zimmer Biomet, Ceramtec, Convatec, TissueGene and MicrogenDx; and has ownership in CD Diagnostics, Hip Innovation Technology, ForMD, Alphaeon, Joint Purification Systems and MicrogenDx. Shohat reports no relevant financial disclosures.