Abstract
Introduction: Management of surgical site infections (SSI) after instrumented spinal surgery remains controversial. The debridement-irrigation, antibiotic therapy and implant retention protocol (DAIR protocol) is safe and effective to treat deep SSI occurring within the 3 months after instrumented spinal surgery.Methods: This retrospective study describes the outcomes of patients treated over a period of 42 months for deep SSI after instrumented spinal surgery according to a modified DAIR protocol.Results: Among 1694 instrumented surgical procedures, deep SSI occurred in 46 patients (2.7%): 41 patients (89%) experienced early SSI (< 1 month), 3 (7%) delayed SSI (from 1 to 3 months), and 2 (4%) late SSI (> 3months). A total of 37 patients had a minimum 1 year of follow-up; among these the modified DAIR protocol was effective in 28 patients (76%) and failed (need for new surgery for persistent signs of SSI beyond 7 days) in 9 patients (24%). Early second-look surgery (≤ 7days) for iterative debridement was performed in 3 patients, who were included in the cured group. Among the 9 patients in whom the modified DAIR protocol failed, none had early second-look surgery; 3 (33%) recovered and were cured at 1 year follow-up, and 6 (66%) relapsed. Overall, among patients with SSI and a minimum 1 year follow-up, the modified DAIR protocol led to healing in 31/37 (84%) patients.Conclusions: The present study supports the effectiveness of a modified DAIR protocol in deep SSI occurring within the 3 months after instrumented spinal surgery. An early second-look surgery for iterative debridement could increase the success rate of this treatment.
Highlights
Management of surgical site infections (SSI) after instrumented spinal surgery remains controversial
Among the 1694 surgical procedures with spinal instrumentation, deep infections occurred in 46 (2.7%) patients who were included in the study
This study describes the outcomes of 46 patients treated for deep surgical site infections after instrumented spine surgery and according to a protocol including surgical debridement-irrigation, antibiotic therapy and implant retention
Summary
Management of surgical site infections (SSI) after instrumented spinal surgery remains controversial. The debridement-irrigation, antibiotic therapy and implant retention protocol (DAIR protocol) is safe and effective to treat deep SSI occurring within the 3 months after instrumented spinal surgery. A protocol including surgical debridement-irrigation (that decreases the bacterial inoculum and allows pathogen identification), intravenous combination antibiotic therapy, and implant retention (DAIR protocol) for deep infections of instrumented spine patients has been proposed. Spinal bone structures are highly vascularized, allowing good penetration and diffusion of antibiotics [7] This is accepted only for early-onset infections (occurring within 30 days of the index surgery), as proposed for prosthetic joint infection [8]; for late-onset infections (>3 months) removal of instrumentation is required in most cases, especially to eradicate biofilm-embedded pathogens, but this is associated with a high risk of mechanical failure if fusion is incomplete. In delayed infections (between 1 and 3 months), there is no consensus but encouraging results have been reported for management using the DAIR protocol [9,10]
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