New Comprehensive Guidelines Aim to Minimize Surgical Site Infections

Pain medicine physicians now have access to newly developed comprehensive guidelines devoted to mitigating infections in patients who undergo surgeries and procedures with regional anesthesia and acute and chronic interventional pain management.

The guidelines—the first comprehensive recommendations of their kind—were published in Regional Anesthesia & Pain Medicine (2025 Apr 1. Printed online.), the official journal of the American Society of Regional Anesthesia and Pain Medicine (ASRA Pain Medicine).

“Interventional pain procedures play a crucial role in pain management,” said David Provenzano, MD, the lead author of the guidelines and president of ASRA Pain Medicine. “It is essential to adhere to best practices to enhance patient safety and minimize the risk of infection. This becomes increasingly important as our procedures continue to advance.”

These recommendations are the first guidelines designed particularly for physicians who manage patients with pain, performing procedures such as in-knee corticosteroid injections, peripheral nerve blocks, and spinal cord stimulation (SCS) for low back and leg pain and drug delivery pump implants. The guidelines also cover antimicrobial resistance, a top 10 threat to global health, according to the WHO.

Surgical site infections (SSIs) are the second most prevalent type of healthcare-associated infection in the United States. Although the infection rate for most pain procedures is very low, treatment still presents challenges and could result in considerable long-term consequences.

“About 50% of all SSIs are preventable when using evidence-based strategies,” said Provenzano, who practices at Pain Diagnostics and Interventional Care, in Sewickley, Pa. “This guideline aims to enhance understanding and raise awareness for evidence-based recommendations related to the field of pain medicine.”

Without treatment, infections from implantable pain therapies can become costly for patients and healthcare systems when serious complications arise. Patients experiencing SSIs can suffer significant morbidity and mortality, including an elevated risk for long-term infections and death. In the event of untreated infections associated with SCS, complications can result in significant morbidity, including paralysis and mortality.

According to data from the Anesthesia Closed Claims Project, infections were the most common cause of adverse events in implantable device procedures for chronic pain. In 2023, the Surgical Care Improvement Project reported a 3% increase in SSIs compared with 2022. SSIs, which account for about 20% of all hospital-acquired infections, cost $3.3 billion annually.

However, there is limited adherence to current evidence-based infection control practices. Compliance rates of 80% or higher were seen in only four of the 15 questions that 506 physicians performing SCS implants answered in a recent international survey.

The new guidelines are the result of a multiyear effort that began in 2020, when ASRA Pain Medicine commissioned the development of evidence-based best practices for infection prevention. To develop sound guidance on risk mitigation, diagnosis and treatment of infectious complications, working groups consisting of four to five members conducted literature searches and devised more than 80 research questions over a three-year period. They used modified U.S. Preventive Services Task Force criteria to assess levels of evidence and certainty.

A total of 23 authors collaborated on the endeavor, including specialists in regional anesthesia, pain medicine, infectious diseases and perioperative care. Their analysis categorized pain procedures into musculoskeletal and peripheral nerve blocks; neuraxial and paravertebral and sympathetic blocks; neuromodulation; and minimally invasive and surgical-type interventional pain procedures.

The guidelines incorporate preoperative patient risk factors and management applicable to a variety of healthcare settings, such as physician offices, hospitals and operating rooms. They also cover sterile techniques, equipment use and maintenance, surgical techniques, postoperative risk reduction, infection symptoms, diagnosis, and treatment. These recommendations also call attention to the significance of factoring in every patient’s unique characteristics, including age and illnesses, such as type 2 diabetes.

The main takeaways include specifics related to environmental cleaning, syringe tip and injection port disinfection, and frequent handwashing. Examples of infection control practices include giving patients IV antibiotics before invasive procedures, using sterile probe covers and ultrasound gel during procedures, and applying bio-occlusive dressings after surgical implant procedures.

The new guidelines will help meet the educational need identified by the CDC and WHO. ASRA Pain Medicine will offer extensive education through online learning and lectures at professional meetings. In addition, hospitals and surgery centers should incorporate the guidelines into staff learning models.

“Pain practitioners have become much more surgical in the last decade or so,” said Sayed Wahezi, MD, the vice president of the scientific affairs committee, treasurer of the American Academy of Pain Medicine and program director of the pain medicine fellowship at Montefiore Medical Center, in New York City. “Guidelines for infection control are extremely important in order to prevent postoperative complications, which obviously corresponds to total healthcare dollars.”

Research indicates that almost three-fourths of patients who suffer an infection and need to have their device removed will not undergo reimplantation, Provenzano said. Costs associated with a healthcare-acquired infection related to an initial SCS are about $60,000 per patient.

“Not only is there a cost burden to society, but it also means that there’s significant impact on patient satisfaction and patient treatment,” Wahezi said.

—Susan Kreimer