by American Society of Regional Anesthesia and Pain Medicine (ASRA)

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The first comprehensive guidelines dedicated to minimizing infections in patients undergoing surgeries and procedures involving regional anesthesia and acute and chronic interventional pain management have been published in Regional Anesthesia & Pain Medicine.

While there are other infection control guidelines, these are the first tailored specifically to physicians who treat patients in pain, including with procedures such as cortisone shots in the knees, peripheral nerve blocks and spinal cord stimulation (SCS) for low back and leg pain, and drug delivery pump implants. The guidelines also address antimicrobial resistance, which the World Health Organization (WHO) considers among the top 10 threats to global health.

These infections are considered surgical site infections (SSIs), which are the second most common type of health care–associated infection (HAI) in the United States. The infection rate for most pain procedures is very low, but when these infections do occur, treating them can be challenging and may lead to significant long-term health effects. Untreated infections from implantable pain therapies can lead to severe complications, such as paralysis and death, and are costly for patients and health care systems.

Yet compliance with existing evidence-based infection control practices is low. A recent international survey of 506 physicians who performed SCS implants found that only 4 of the 15 questions had compliance rates of 80% or higher.

“Due to the increasing complexity of interventional pain procedures, the rapidly advancing field and a lack of evidence-based recommendations, there is inconsistency in the practice of regional anesthesia and acute and chronic pain medicine related to infection prevention and management,” said David A. Provenzano, M.D., lead author of the guidelines and president of ASRA Pain Medicine.

“These new guidelines help address these issues and improve outcomes. Following them can make a real difference as we’ve seen in other surgical subspecialties, which have decreased the rate of SSIs after complying with evidence-based infection control strategies.”

The development of ASRA Pain Medicine’s infection control guidelines involved 23 authors, including specialists in regional anesthesia, pain medicine, infectious diseases and perioperative care. They analyzed more than 80 research questions over a three-year period, classifying 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 address preoperative patient risk factors and management in various health care settings (office, hospital, operating room), including sterile techniques, equipment use and maintenance, surgical techniques, postoperative risk reduction, infection symptoms, diagnosis, and treatment. The recommendations also emphasize the importance of considering each patient’s unique characteristics, including age and health conditions such as diabetes mellitus.

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

In 2023, the Surgical Care Improvement Project (SCIP) noted a 3% increase in SSI compared to 2022. SSIs represent about 20% of all HAIs and cost $3.3 billion annually.

“SSIs can cause significant patient suffering,” said Dr. Provenzano, an interventional physician in Pittsburgh. “For example, patients receiving a spinal cord stimulator implant may abandon therapy if they get an infection following the surgery. Research shows nearly three-quarters of patients who experience an infection and need to have their device removed will not have a new one implanted.” Costs associated with an HAI related to an initial SCS are approximately $60,000 per patient, he said.

The new guidelines will help fill the educational need identified by the CDC and WHO, and ASRA Pain Medicine will provide extensive education around the guidelines through online learning and lectures at professional meetings. In addition, the guidelines should be incorporated into staff learning models at hospitals and surgical centers.

More information: David Anthony Provenzano et al, ASRA Pain Medicine consensus practice infection control guidelines for regional anesthesia and pain medicine, Regional Anesthesia & Pain Medicine (2025). DOI: 10.1136/rapm-2024-105651

Provided by American Society of Regional Anesthesia and Pain Medicine (ASRA)

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