For the first time in its 50-year history, the American Society of Regional Anesthesia and Pain Medicine (ASRA) has released a comprehensive set of consensus practice guidelines dedicated to infection control for regional anesthesia and pain medicine. The guidelines, published in January, are the first explicitly tailored to regional anesthesiologists and pain specialists, and offer recommendations on risk mitigation, diagnosis and treatment of infectious complications associated with the practice (Reg Anesth Pain Med 2025 Feb 11. doi:10.1136/rapm-2024-105651).

“The impetus for this undertaking was a series of surveys we performed back in 2015 and 2016, which demonstrated a knowledge deficit in the practice of interventional pain medicine when it came to following best practices for infection control,” said David A. Provenzano, MD, the president of ASRA and lead author of the guidelines.

“On the other hand, we know from the CDC that approximately 50% of all SSIs [surgical site infections] are preventable if we follow best practices,” he continued. “So our goal was to inform practitioners of these practices. We’re truly hopeful that the guidelines will make a huge difference in terms of patient outcomes.”

The product of 23 authors’ efforts—including specialists in regional anesthesia, pain medicine, infectious diseases and perioperative care—the guidelines are built around more than 80 research questions that classify pain procedures into categories such as musculoskeletal and peripheral nerve blocks; neuraxial, paravertebral and sympathetic blocks; neuromodulation; minimally invasive pain procedures; and surgical-based interventional pain procedures.

From there, assigned working groups of four to five members performed relevant literature searches for each question. Modified U.S. Preventive Services Task Force criteria were used to determine levels of evidence and certainty; a modified Delphi method was employed before specific recommendations were accepted by the working group. Ultimately, the society’s board of directors reviewed and approved the final guidelines.

More than 35 pages in length and comprising a mind-boggling 684 references, the guidelines draw strength from their comprehensiveness, covering a broad range of topics regarding preoperative patient risk factors and management in various healthcare settings. The recommendations also emphasize the importance of considering each patient’s unique characteristics, including age and health conditions.

“The goal here is prevention, and these guidelines do a very nice job of summarizing those questions and consensus statements while also focusing on identification and prompt management,” said co-author Christine L. Hunt, DO, a physiatrist and pain management specialist at Mayo Clinic in Florida, Jacksonville. “Because in our experience, in those rare cases where infection does occur, you can avoid harm to the patient with prompt and effective management. And that’s what these guidelines really endeavor to do.”

The document addresses these lofty goals by first defining SSIs and associated pathogens, after it lays the groundwork by identifying infection rates and defining infectious complications in various regional anesthesia and interventional pain procedures. From there, the guidelines address the role of anesthesiologists in perioperative risk reduction strategies from environmental cleaning to proactive infection mitigation strategies. In the same vein, the guidelines also tackle patient risk factors and risk reduction optimization strategies.

Preprocedural recommendations follow and address preoperative antibiotic administration for pain therapy procedures; hand hygiene and skin antisepsis for procedural staff; hand scrub time recommendations; procedural practices in aseptic technique; the impact of barrier protections; patient skin antisepsis; and single- and multidose medication vials. However, procedural recommendations address topics such as use of fluoroscopy; ultrasound-guided regional anesthesia and pain procedures; ultrasound transducers, gel and probe covers; and peripheral nerve catheters.

The guidelines then delve into specific measures to be undertaken with respect to surgical technique, including discussion and recommendations of surgical incisions; local anesthetic with epinephrine; surgical time; gloving techniques; wound irrigation; and skin closure techniques. In the realm of post-procedural recommendations, the guidelines touch on topics such as postoperative antibiotics for implantable pain therapies; diagnosis and treatment of pain procedural infections; central nervous system infections; treatment and outcomes of infectious complications following neuraxial blocks; management of perioperative fever; and the management of infected pain device implants.

In fact, implantable devices garner so much attention in the guidelines that an entire section is dedicated to the prevention and challenges of treating infections associated with these devices. This section addresses postoperative wound management for device explant procedures, antibiotic treatment for implantable device infections, infectious disease consultations and recommendations for reimplantation of implantable pain devices after SSIs.

“When it comes to implantable devices, infections can start in a number of different places,” Hunt said. “But if you promptly remove the device and treat the patient with antibiotics, you can often avoid hospitalization. Then, if the patient needs to have the device implanted again, you can control for whatever risk factors led to the infection in the first place.

“So you want to treat every case with a heightened level of concern before it ever gets to that,” she added.

This, she said, is a particularly important consideration given that in the United States alone, SSIs are the second most common form of healthcare-related infection and are associated with total healthcare-related costs exceeding $3 billion annually.

“Surgical site infections occur infrequently, but when they do happen, you have to go after them quickly and aggressively,” Provenzano said. “This is especially important in light of the fact that our procedures have become much more complicated over the last five to 10 years.”

As Provenzano noted, the guidelines will help fill an educational void identified by the CDC and WHO. Moreover, ASRA Pain Medicine plans on providing ongoing education around the guidelines, both through online platforms and lectures at professional meetings. They also recommended that the guidelines be incorporated into staff learning models at hospitals and surgical centers.

“In conclusion, a significant number of infections are preventable,” Provenzano said. “Since the morbidity associated with infections is quite significant, it’s important best practices are followed, to minimize the occurrence of infection. So we really want to encourage those practices.”

By Michael Vlessides

Hunt and Provenzano reported no relevant financial disclosures.