What Do the SCIP Guidelines "SKIP"? Commentary on an article by Brent Ponce, MD, et al.: "Surgical Site Infection After Arthroplasty: Comparative Effectiveness of Prophylactic Antibiotics. Do Surgical Care Improvement Project Guidelines Need to Be Updated?"

Abstract

Commentary Infection after joint replacement remains a potentially devastating complication. On a national scale, the Centers for Disease Control and Prevention have estimated an annual incidence of 500,000 surgical site infections (SSIs)1. The Surgical Care Improvement Project (SCIP) is a collaborative effort of national organizations aligned by a common goal: the improvement in surgical care by the reduction of postoperative complications2. Implemented in 2005, the SCIP set a goal of reducing the incidence of surgical complications by 25% by 2010. Of a series of ten measures, three apply to the timing of antibiotic initiation (SCIP-inf-1), antibiotic selection (SCIP-inf-2), and antibiotic cessation (SCIP-inf-3). In summary, prophylactic antibiotics should be initiated within one hour of the surgical incision and discontinued within twenty-four hours of the cessation of surgery. Antibiotics should be selected on the basis of likely pathogens, and the recommendations for total hip and knee arthroplasty are for the use of cefazolin or cefuroxime, or for vancomycin or clindamycin in a patient with a beta-lactam allergy. Ponce et al. present the findings of a retrospective review of the use of cefazolin, vancomycin, cefazolin and vancomycin, or clindamycin as antibiotic prophylaxis in 18,830 patients undergoing elective primary or revision total hip or knee arthroplasty at ninety-four hospitals in the VA (Veterans Affairs) system. The first conclusion drawn was that the use of vancomycin only led to the highest early SSI rate. The SSI rate (combining both superficial and deep infections) at thirty days was 2.3% for vancomycin compared with 1.5% with vancomycin plus cefazolin, 1.3% for cefazolin only, and 1.1% for clindamycin. Vancomycin is a narrow-spectrum antibiotic, and the finding of a higher infection rate seems logical. The use of vancomycin only for antibiotic prophylaxis may not be adequate. The second conclusion was that the antibiotic dosage, and not merely the antibiotic choice, should be specified in the SCIP guidelines. Given that a vancomycin dosage of 15 mg/kg is generally accepted as appropriate but a standard dose of 1 g (appropriate for a patient weight of 67 kg) is often given, many of the patients who received vancomycin were potentially underdosed. The study was not, however, able to address the direct association between the antibiotic dosage used and the subsequent infection rate. The reader should be aware of several other limitations noted by the authors of this study. First, the data did not allow identification of the organism responsible for the SSI. As has been shown by Finkelstein et al., the antibiotic itself may be predictive of the infecting organism3. Second, the specific biogram of each hospital and its influence on the infection rate resulting from the antibiotic choice could not be determined. Meehan et al. showed that vancomycin may be appropriate in hospitals with a high prevalence of methicillin-resistant Staphylococcus aureus4. Third, superficial and deep SSIs were grouped as a single category, but the underlying causes of these two infection types may not be the same. The authors are to be congratulated for pointing out the potential influence of antibiotic dosage on postoperative infection. The use of SCIP guidelines represents a national initiative to standardize the perioperative treatment of patients. These guidelines are not perfect; for example, the requirements designed to prevent venous thromboembolic (VTE) events may come with the downside of postoperative bleeding5, and the goal of never having a postoperative VTE event would seem impossible to achieve6. As we continue in the use of SCIP guidelines, improvements will be made. The identification of the potential need for antibiotic dosage guidelines in addition to the guidelines that currently exist for the timing, choice, and duration of antibiotic usage becomes important as we continue to focus on improving patient safety and minimizing postoperative infection.