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What: Surgical site infections are estimated to cost about $10 million annually and are the 2nd most common form of healthcare-related infection in the United States. Experts at the American Society of Regional Anesthesia and Pain Medicine are available in this virtual press briefing to discuss new infection control guidelines to be published January 21, 2025. 

Who: Dr. David Provenzano, ASRA President

When: Tuesday, January 14th at 3 PM ET

Where: º£½ÇÉçÇø Live Zoom Room (address will be included in follow-up email)

Moderator: Hello and welcome to today's º£½ÇÉçÇø live virtual press briefing. I'm here with representatives from ASRA pain medicine to talk about the new infection control guidelines that they will be publishing next week. The contents of this discussion are under embargo until those new guidelines are published on the 21st. We will be recording this briefing and have a transcript and a video available to media after it's all concluded. I'd like to go ahead and introduce first Dr David Provenzano. 

Dr. Provenzano: Sure. First of all, thanks so much for having us today. I'm Dave Provenzano. I'm currently the president of ASRA pain medicine, and thank you for all the media that's joined. We're really excited. This project's been four years in the making, we had 22 other authors that I'd also like to thank will be listed when it comes out. And also like to thank Dr. Hunt for joining today. So these are the ASRA pain medicine consensus practice, infection control guidelines for regional anesthesia and pain medicine. These guidelines as Pain Physicians, we start with acute pain management, and we go to chronic pain management, and the techniques substantially vary as you go from acute to chronic pain management. And so what we did in this is we actually provided best practices to reduce the incidence of infection to prevent infection, and then when infection does occur, no matter how good we are, what are the best strategies to deal with it? There's over 80 questions. The articles about 37 text pages with over 600 references, and it fully encompasses from pre operative to interoperative, to post operative, and covers procedures such as regional anesthesia, nerve blocks, epidural steroid injections, joint injections, to our more invasive procedures, which involve implantable pain therapies. And the real impetus for this is that we've done a few surveys back in the 2015-16 time frame, which showed that there was a knowledge deficit in the practice of interventional pain medicine when it came to following best practices. And we know from the CDC that they believe that about 50% of all surgical site infections are preventable if we had followed best practices, and so this impetus of this is to inform practitioners of best practices to improve patient outcomes. And we always try to do this at ASRA pain medicine with all our guidelines. And we're truly hopeful that this guide moment will make a huge difference.

Moderator: I'd like to also introduce your colleague, Dr. Hunt, and ask to tell us, please, if you can your name, where you work, and a little bit about how these guidelines are not only about prevention, but also treating and identifying, intervening, you know, with those best practices if infections do occur, tell us a little bit about that, Dr Hunt.

Dr. Hunt: Thank you so much. My name is Christine Hunt. I'm a pain physician at Mayo Clinic in Florida, and I really appreciate the opportunity to be here. I think Dr. Provenzano, he's led an unbelievable effort to develop these guidelines. I just want to just mention briefly these are really important because when it comes to having true consensus on identification, on prevention, identification and management of infection as a field, this is something that's really important for us to come together on. We are a multi disciplinary field, which is a strength that's actually a strength of ASRA pain medicine as well, where we're a multi disciplinary Pain Society and as such, you know, we really want to make sure that we're being proactive in terms of when infections do happen again, fortunately, although rare, when they do happen, having a consensus way of making sure we're dealing with those appropriately when it comes to identification of infection, these guidelines do provide sort of what are their classic signs and symptoms that practitioners might expect to see. This is very helpful for physicians, also for advanced practice practitioners like your physician's assistants and PAs as well as nurses. So this is designed to be comprehensive and accessible, so the range of presentation is going to vary, like Dr. Provenzano mentioned, this is covering a variety of pain interventions, from single shot nerve blocks to joint injections to implantable pain therapies. And so how those present is obviously going to differ based on the procedure that was performed including time course. But universally amongst these, what's very important is prompt identification and not just relying on things that are more classic when you think of infection, right? When you think of infection, you might think of fever, for example, but there are many patients with infection who don't present with fever. So understanding the nuances of and how, of how that presents, and what to be proactive and look for is really important, as well as to inform patients what to be on the lookout for. And then, when it comes to management, identification is important. Diagnosis is important, as well as the right types of lab tests to perform, diagnostic imaging that should take place, consultative services to bring in. In the case of implantable pain therapies, perhaps getting infectious disease on board can be important, but dealing with that promptly without delay can be very helpful in preventing morbidity to the patient, right? So really, the goal here is prevention, and these guidelines do a very nice job of summarizing those guidelines and consensus statements, but then also identification and prompt management. We do see whenever in the rare case of infection does occur, you can avoid harm to the patient with prompt management and effective management. So that's what these guidelines really endeavor to do. We're very specific in terms of what we recommend, and certain, like I said, certain lab tests to look to order and check for, and how to go about moving forward. And specifically, for example, in the case of implantable pain therapies, that can often include prompt removal or explant of the device, which really kind of removes that problem, patients may need to be on antibiotics for a prolonged period afterward, but identification is important, and there are differences across the board that I've seen, not necessarily my own practice, but in the field of pain medicine in general, sometimes there's delay in recognition, and patients can be, you know, experiencing an infection for some time. Want to make sure we avoid that, so these guidelines do endeavor to provide guidance in that respect as well.

Moderator: Members of the media on the call, please. You're welcome to chat questions that I will then ask of our panelists for you, Dr. Provenzano, if you could tell us a little bit about the types of procedures and the types of clinicians that these new guidelines are meant to aid, what could patients reading about this understand for any kind of procedures, surgeries that they may have coming up about their own health and the types of positions and what sorts of situations this is really geared toward assisting.

Dr. Provenzano: Sure, gladly, will answer that and just would like to add to something that Dr Hunt talked about about prompt recognition and treatment of these infections, although fortunately, they happen infrequently, but when they do happen, you have to mitigate and really go after these infections, and this has been shown in a chronic pain implantable device infection was a big nationwide sample done in hospitals, and actually, when these devices were not promptly removed, there was a higher risk of mortality and also significant complications such as paralysis. But when they were effectively removed and taken care of these risks went substantially down. So I think I cannot highlight more. Infections do happen and you have to intervene when you look at who these guidelines are working for. So let's go over the procedures again. These stem from regional anesthesia. These are the blocks that we do to make people extremely comfortable prior to a surgery. And so this would be for the anesthesiologist practicing in the OR, however, when you look at or it may even be for the emergency medicine physician that's practicing the ER, that's trying to provide comfort to the patients that may have had a hip fracture. And then when you look at chronic pain procedures, they're done by a variety of physicians, physiatrists, anesthesiologists, neurosurgeons, orthopedic surgeons, emergency room physicians that have been appropriately trained and people that have done on a pain fellowships. So it's going to affect multiple specialties. And as Dr. Hunt said, ASRA, pain medicine is open to all specialties that practice pain medicine. There's also one section there too, I think that's really helpful, is to the role of the anesthesiologist that practices knee in the OR that provides, possibly the anesthetic care to the patient. And we talk about how that can be optimized, and what our role as an anesthesiologist is, even when we're not doing the blocks, how you can mitigate the risk of infection when you look at the procedures again, we have regional blocks which are to provide acute pain control. Often. We have spinal procedures such as epidural steroid injections, which is one of the most commonly performed pain procedures. We have procedures such as facet interventions to treat arthritic joints. Our procedures have become much more complicated over the last five to 10 years, with such things as the minimally invasive lumbar decompression procedures, where we go in and we help take part of the ligament that's compressing the spinal canal. And then we also have implantable pain therapies, which many people are familiar with, spinal cord stimulators, intrathecal pumps, dorsal root ganglion stimulators and sacroiliac joint fusion. So these are extremely important. 

Moderator: And tell us a little bit the context of how big of a problem this is. Are there large numbers of patients affected by this regularly, and how much do you think that this can be cut down by following the new best practices?

Dr. Provenzano: Sorry about that. So if you look at this, I think they can be substantially cut down. So if you look again, we have low infection rates, but when they do happen, they're significant. So let's take something like implantable pain therapies. Implantable pain therapies, when you look at Nationwide large surveys, the infection rate's about 3% however, in some of our studies, they've been even higher than that, not my personal studies, but in publications. So but when you look at what the CDC said again, about 50% of all infections that occur were most likely preventable if best practices were followed. So let's take in something like an implantable pain therapy, like a spinal cord stimulator. We know if that device gets infected, over 75% of them have to come out. We know that the cost is at least about $60,000 and that may not even involve the replacing the implantable therapy, and we know only about 27% of patients ever get their device back. And so what that means is that not only did they have an infection, but they lost the device which was providing them pain control, and often it's the last therapy that they had to utilize. So in conclusion, a significant number of infections are preventable. Best strategies are followed, and the morbidity that is associated with infections is quite significant. So we really want to encourage best practices. 

Moderator: And that cost not only about removing a device that's been implanted, but the cost of care for that patient, then is going to increase, I presume, because of needing antibiotics, potentially needing other methods of pain management. What else is involved? If you're having a patient, experience this type of infection that can help people understand why it's so important to try to prevent this.

Dr. Provenzano: Yeah, so, I mean, you're exactly right. So first, the most important thing is the patient, right? And we'll have Dr. Hunt talk about this a little bit too, but no one wants a patient to get an infection, and can be quite devastating to the patient. So that's the most important thing. And then what? And then when you look at the economic costs, we know that surgical site infections in the United States cost about $3 billion annually. So this is a huge cost driver, and things that are associated with infections are, one is you have the cost of caring for the patient, which could be antibiotics, could be an extended hospital stay, could be post operative care and you're providing prolonged antibiotics and the outpatient basis. You may have to re-operate, you may have to remove the device. You can have to consult other services section, infection control, to appropriately manage these patients so that the costs are extensive, whether it comes from surgical costs, pharmaceutical costs, inpatient costs and additional clinical and physician costs.

Moderator: Dr. Hunt tell us a little bit about what that experience is for a patient having to deal with this type of infection to give people, again, further understanding of why it's so important to avoid this. 

Dr. Hunt: So I'd like to, if you don't mind, also talk a little bit about specifically in the case of implantable pain therapies, or even something like a tunnel, like a peripheral nerve catheter right on the acute side. Let's take an epidural. Let's take either an epidural catheter, even a peripheral nerve catheter on the acute side. So I'm about chronic pain therapies, but on the acute side, if you can identify right away, here's what an infection starts to look like, and let's simply remove this peripheral nerve catheter. You can avoid entirely complications from an infection right now, take that principle and expand it also to implantable pain therapies, right? So in the case of a peripheral nerve catheter, which is, you know, putting a little tube down where you administer anesthetic by a nerve in order to help a patient feel more comfortable after a major surgery. If it's very rare for these to become infected, but again, if it happens, you might notice a little bit of redness or irritation on where the catheter starting to come out. You simply remove the catheter, eliminates the problem. Maybe the patient needs to be a little bit of antibiotics, but often it's just simply removal of the catheter. You kind of stop the problem before it even really starts. And that's actually a very, really important thing when it comes to some of these, what Dr Provenzano was talking about in the case implantable pain therapies, a spinal cord stimulator implant or a pump. So for example, the guidelines show when they do the literature review where there was a high cohort with a higher risk of infection was a very high risk cohort, pediatric patients on baclofen pumps. These patients have problems with neurogenic skin, higher risk for skin breakdown, higher risk for infection. Knowing how to manage such a vulnerable population is really important. So getting back to the kind of that patient's experience, where these infections often start is in either the battery, in the case of an implant, or this sort of reservoir where the medication lies in the case of a pain pump, right that the pump itself. And by definition, these components of the system reside in the soft tissue and a space that, if it becomes infected, if you promptly, if you manage it appropriately, if you promptly remove the device when that's needed again, majority of cases that's going to be required. If you can probably remove that and shoot with antibiotics, you can avoid hospitalization. You can avoid significant morbidity in the patient, if the patient needs to have the device put back in, and you can control for whatever risk factors led to that infection in the first place. They can resume their therapy, right and be able to have that back if it was helpful for them in the first place. What you don't want to have happen is and when, where that infection is most likely to start or take place is going to be in that soft tissue where the device is. The guidelines go into this. But the reason for that has to do with the device itself and kind of a biofilm that can form around the implant or the battery. And that's there's really no way to prevent that. That just will be what happens. And if infection is likely to take place, that's where it's going to be. But that gives you some time, because, like the guidelines say they kind of talk about, here's what an infection looks like. It's often accompanied by some pain, some swelling, some more, maybe, or maybe not, a fever. But you can kind of see that really nicely and clearly in the superficial space. And if you are prompting your recognition and prompting your management, you can prevent the infection from ever spreading toward the spine itself, which is really where you start to see that high morbidity. That's where you're more likely to see a problem like paralysis or severe illness, sepsis, like even an infection in the spine itself. Those are, those are the really high morbidity concerning cases. So you want to treat every case with a heightened level of concern before it ever kind of gets to that space. So when it comes to the safety of the patient and the patient's overall experience, prompt recognition is extremely important, because if you recognize it promptly and manage it promptly, you can almost every time, avoid major morbidity of the patient. You can take the device out, treat with antibiotics, and patients can do really well, not even require hospitalization, but that, like I said, that requires prompt management, early recognition, and then appropriate diagnosis you want to check for, is there any evidence of infection more widespread in the blood? That's going to need a different type of problem, right, like a bloodstream infection or an infection of the spine. You have to be comfortable with how to recognize that, and the guidelines do go into that so that we can take great care of patients at the end of the day, that is what is most important, economic costs. It's very important to be excellent stewards of our resources, but at the end of the day, we want to make sure that we're taking good care of patients. What's tough about pain therapies, whether it's a single shot block or a joint injection or implantable pain therapy, is at the end of the day, these are elective procedures designed to treat patients who are suffering and feeling poorly, helping them to feel better, right? And so it's that much more important in the case of elective procedures, to be fastidious when it comes to infection prevention, recognition and management.

Moderator: Dr. Provenzano, when it comes to hospitalization and surgeries, many people are familiar with the growing problem of antibiotic resistance, and I wonder if you can talk a little bit about how much that is a factor in this, and Are there risks of patients developing these kinds of infections that come along with any sort of antibiotic resistance that might complicate things further?

Dr. Provenzano: Yeah, that's an excellent question. So there's no doubt recently that antibiotic resistance has been a hot topic. It's been a hot topic for many years, and this is very clear with the World Health Organization recently discussing this and the best way? Obviously, antibiotics are a great tool for physicians. They're a great way to limit the risk of infection. However, they have to be appropriately utilized and used for appropriate indications, and we address that based on a stringent review of the evidence on when antibiotics should be utilized, how they should be dosed. One of the keys with antibiotics is weight based dosing. Not everyone is the same weight, and if you do not weight based dose antibiotics, you never reach minimum inhibitory concentrations, possibly. And if you don't reach that, then you may not effectively treat the infection. We know that antibiotics, pre operatively, are the most powerful when appropriately given and timed, appropriately based on recommendations. So we talk about that. Then the second thing which has been highlighted in our in our fields surveys, is that, unfortunately, sometimes in physicians trying to be really good stewards, they continue antibiotics for prolonged periods of time after we have performed possibly a peripheral catheter or a peripheral nerve stimulator, or we've done an implantable pain therapy, and we're trying, I think most physicians would say they were trying to prevent infection, but the guidelines clearly show that we should not be continuing antibiotics in the post operative period for individuals that do not have infections, and that if you are going to continue it for implantable therapies, it should not be continued beyond 24 hours after the surgery, and the biggest key is the pre operative dosing. So we discussed that extensively, we reviewed the evidence, rated it with the United States Preventive Task Force, and provide recommendations to heighten awareness on the appropriate use of antibiotics, with the goal of improving outcomes and also, as you stated, decreasing the reality that can occur with antibiotic resistance, which can cause significant impact, not only to your patient, but also to the whole field of medicine, because as we develop more antibiotic resistance, it's harder to treat infections. We're basically creating superbugs. 

Moderator: Dr. Provenzano, tell us how physicians will be able to access these guidelines when they're ready and published next week. What's the way that they will be informed about this and be able to learn what's included there. 

Dr. Provenzano: right? So again, I'd like to thank all the co-authors that just spent years of their time, including Dr. Hunt, who was extremely instrumental in these guidelines and really took a leadership role. So these guidelines will be released next week. They will be published in our premier journal, regional anesthesia and pain medicine, which we're very proud of. It's an excellent journal. These have gone through an extensive review process. They will be released next week, and they will be available through our journal, regional anesthesia and pain medicine, and they'll also be available through our website at ASRA pain medicine, there'll be a link to the guidelines.

Moderator: For members of the media I've sent in the chat the email address for Elizabeth at ASRA pain medicine, so that you can request a copy of those guidelines and ask any further follow up questions that you have, Dr. Provenzano or Dr Hunt. Do you have any other comments that you'd like to share about these guidelines and what you hope that the media and the public can learn from them.

Dr. Provenzano: I'll let Dr Hunt go.

Dr. Hunt: I was gonna say, I wanna, I'll go first so Dr. Provenzano can have the last word. I just, I just wanna echo what Dr Provenzano has said in terms of this being a true labor, labor of love. I feel for the patients. Right, every single author involved in these guidelines is a clinician. First, we're all, every single day, working on the front line, so to speak, to try to help patients who deal with acute and chronic pain. And the people who are involved in writing these guidelines are truly invested in understanding and disseminating information that can be really helpful for helping people in the real world, very practical information to improve practice, improve patient safety and quality. So I just really want to highlight that in the work of everybody who was involved in this was years in the making. And Dr. Provenzano, especially, he was a fantastic leader, his vision for the project and the I mean, unbelievable, countless hundreds of hours he has spent on this project to make sure that it is the very highest quality that could be. I'm just so thankful for his leadership and for the ability to participate in this overall, I just want to say that I am really hopeful and optimistic that these guidelines are going to positively impact patient care. I'm the vice chair of quality of my institution. I think a lot about patient safety quality, but you don't have to have any particular title, any, every physician, this is what we care about almost more than anything else, right? I want to make sure that as much as we're helping patients, we're doing so in a safe way, and I think these guidelines truly will impact that care. I have seen, you know, I have had calls, texts, “hey, I've got this situation going on. How would you recommend I proceed when it comes to infection?” Again, it's rare, but when it happens, you need something right in front of you that gives you something that's comprehensive but practical, and these guidelines deliver that. So I think this is gonna help ensure that the patient will get the same kind of quality of as makes it possible for the patient to get the same kind of quality of care when it comes to infection prevention, recognition and management, whether they're seeing Dr. Provenzano in his office, or if they're in, you know, a different kind of facility with different set of resources. So I'm very thankful for that, and at the end of the day, that's what's most important, is this improves safety and quality for patients.

Moderator: Thank you. Dr. Hunt, Dr. Provenzano, what would you like to add as closing thought? 

Dr. Provenzano: Yeah, again, I would just echo those thoughts. I mean, we're really excited about this. I think this will help the whole transition of the patient through all the pain procedures throughout the operating room and also with post operative care, and I'm very hopeful. I think most physicians, all physicians, want to provide high quality care. And ASRA pain medicine, our guidelines have really been our hallmark, and this will be another guideline to help improve patient care. So I want to also thank ASRA pain medicine for being willing to support these guidelines.

Moderator: Thank you very much Dr. Hunt and Dr. Provenzano from ASRA pain medicine. Members of the media, please feel free to follow up with Elizabeth at ASRA pain medicine to get a copy of these guidelines and ask any other follow up questions that you have. We will provide a video and a transcript of this briefing and send those to you by email shortly. With that, I will say thank you very much to Dr. Hunt and Dr. Provinceano. And goodbye. Good luck and stay safe.

Dr. Provenzano: Thank you, everyone. Bye bye.