New Guidance Aims to Reduce Surgical Infections

New guidelines from the American Society of Regional and Anesthesia (ASRA) Pain Medicine offer strategies for anesthesiologists and pain physicians to prevent infections that develop after surgery and other pain procedures.

Surgical site infections (SSIs) — which by some estimates occur 500,000 times annually in the United States— increase hospital costs by more than $20,000 per admission and extend stays by almost 10 days, according to the Centers for Disease Control and Prevention. Besides the economic costs, some patients who have an SSI will experience long-term infection and earlier death.

“This puts together guidelines and practices in one place, well supported by the literature,” said Christine Hunt, DO, a physiatrist at Mayo Clinic in Jacksonville, Florida, who helped write the new recommendations. The guidelines offer suggestions from the perioperative setting through chronic pain management, Hunt added.

The incidence of SSIs linked to regional anesthesia or interventional pain procedures is hard to pinpoint, according to the authors of the new guidelines. Some scholars estimate the overall incidence of SSIs could be halved by better adherence to evidence-based infection control practices.

Grading the Evidence

Hunt and her colleagues assessed papers from 1995 to 2024 on infection management strategies during pain procedures.

They grouped pain prevention procedures into four types, with suggestions for infection prevention offered before, during, and after a procedure: Musculoskeletal and peripheral nerve blocks, such as a trigger point injections; neuraxial and paravertebral procedures like epidural corticosteroid injections; neuromodulation, intradiscal and minimally invasive procedures like a basivertebral nerve ablation; and surgical interventions, such as sacroiliac joint fusions.

“This provides all of your guidance right there,” Hunt said.

Some approaches were general: Washing with soap and water before the first case of the day and use of hand sanitizer for at least 15 seconds are recommended before every type of procedure. But others were more specific — antibiotic prophylaxis before minimally invasive or surgical procedures, for example, or maintaining perioperative blood glucose at 150 mg/dL or lower before surgery to implant devices such as spinal cord stimulators.

The patient’s microbiome is an increasingly recognized source of infection, said Jessica Seidelman, MD, MPH, an epidemiologist and infectious disease physician at the Duke Infectious Disease Clinic in Durham, North Carolina. Seidelman, who was not involved in drafting the guidelines, stressed the importance of protecting the microbiome in general.

“How do we best decrease the bioburden of microorganisms at the site where you are breaching the skin, doing that surgery, doing that procedure? You’re never going to eliminate the organisms completely, but you can reduce them to the point where they’re hopefully not going to cause an infection,” Seidelman said. Antisepsis of the surgical site is essential, Seidelman added — both selecting the right agent and applying it correctly.

Seidelman said surgeons and infection prevention experts tend to research and publish regularly about preventing SSIs, with perhaps not as much focus on this topic among anesthesiologists. The ASRA Pain Medicine guidelines are useful for bringing the anesthesiologist’s perspective forward.

“The anesthesiologists are in the room. They play a pivotal part in this. They really need to be at the table and part of this conversation,” Seidelman said.

One inadvertent source of infection could be time pressure, Seidelman said. Anesthesiologists and other clinicians feel obliged to hurry between procedures based on messages they’ve received from hospital or clinic leaders.

“We need to be more cognizant and patient so that people don’t feel, ‘Oh gosh, I need to be in and out of this room in 10 minutes. Otherwise, I’m going to get slapped on the wrist,” Seidelman said.

Hunt said many pain management procedures are elective, providing time and space to attend to infection control, Hunt added.

“It’s an elective procedure. There’s really no reason not to adhere to best practices. You’re not under pressure to try to do something quickly when a patient isn’t optimized,” Hunt said.

For example, biologics used to control rheumatoid arthritis may leave someone more susceptible to infection during a pain relief procedure like implanting a pain pump or spinal cord stimulation. Since the procedure is scheduled in advance there’s time to consult with a rheumatologist to see if and when it is safe to stop taking the biologic temporarily, Hunt said.

Hunt reported grant funding from Nevro. Seidelman reported no relevant financial conflicts of interest.

Marcus A. Banks, MA, is a journalist based near New York City who covers health news with a focus on new cancer research. His work appears in Medscape Medical News, Cancer Today, The Scientist, Gastroenterology & Endoscopy News, Slate, TCTMD, and Spectrum.