Surgical Site Infection In Spinal Surgery Research Articles

Frailty Influence on Postoperative Surgical Site Infections After Surgery for Degenerative Spine Disease and Adult Spine Deformity. Can a Frailty Index be a Valuable Summary Risk Indicator? A Systematic Review and Metanalysis of the Current Literature.

Metanalysis. Surgical site infections (SSI) is one of the commonest postoperative adverse events after spine surgery. Frailty has been described as a valuable summary risk indicator for SSI in spine surgery. The aim of this metanalysis is to evaluate the influence of frailty on postoperative SSI in this cohort and provide hints on which index can predict the risk of SSI. Papers describing the postoperative SSI rate in adult degenerative spine disease or adult spine deformity patients with varying degrees of frailty were included in the analysis. The SSI rate in different grades of frailty was considered for outcome measure. Meta-analysis was performed on studies in whom data regarding patients with different levels of frailty and occurrence of postoperative SSI could be pooled. P < .05 was considered significant. 16 studies were included. The frailty prevalence measured using mFI-11 ranged from 3% to 17.9%, these values were inferior to those measured with mFI-5. Significant difference was found between frail and non-frail patients in postoperative SSI rate at metanalysis (z = 5.9547, P < .0001 for mFI-5 and z = 3.8334, P = .0001 for mFI-11). This is the first meta-analysis to specifically investigate the impact of frailty, on occurrence of SSI. We found a relevant statistical difference between frail and non-frail patients in SSI occurrence rate. This is a relevant finding, as the ageing of population increases alongside with spine surgery procedures, a better understanding of risk factors may advance our ability to treat patients while minimizing the occurrence of SSI.

Reducing the rate of surgical site infection using iodophor-impregnated adhesive incision draping in spine surgery compared with standard adhesive incision draping: a study in 2279 patients.

While adhesive incision drapes are widely used for reducing surgical site infection (SSI), evidence remains scarce on whether impregnated adhesive incision draping can further reduce the rate of SSI in spine surgery. All patients treated surgically in the authors' high-volume university spine center from January 2018 to December 2021 were retrospectively evaluated and divided into cohorts treated before (the control cohort) and after (the study cohort) introduction of an iodophor-impregnated adhesive incision drape (instead of a standard nonimpregnated adhesive incision drape) at their institute. Epidemiological aspects, baseline characteristics, operative records, and rate and characteristics of postoperative SSI were analyzed and compared between cohorts. Two thousand two hundred seventy-nine consecutively treated patients were included, with an overall SSI rate of 0.5%. Baseline patient findings and surgical characteristics (including indication, localization, procedure, and duration of surgery) did not significantly differ between the 1125 patients in the control cohort and the 1154 patients in the study cohort. Uni- and multivariate analyses showed that use of an iodophor-impregnated adhesive incision drape was the only factor significantly associated with a lower risk of SSI. The SSI rate was significantly lower in the study cohort (0.2% vs 0.8%, p = 0.036). While germs of the skin microbiome such as Staphylococcus epidermidis and S. aureus were predominantly prevalent in both cohorts, fecal germs such as Enterococcus/Enterobacter species were found only in the control cohort and not in the study cohort. The use of iodophor-impregnated adhesive incision drapes in spine surgery can help to lower the rate of postoperative SSI and aid in reducing the risk of fecal germ infections.

Effectiveness of Gentamicin Wound Irrigation in Preventing Surgical Site Infection During Lumbar Spine Surgery: A Retrospective Study at a Rural Teaching Hospital in India.

Surgical site infections (SSIs) are an opposing result of surgery and account for the majority of healthcare-related infections worldwide. It is one of the most common complications associated with open-spine surgery and is associated with high rates of mortality and high demand for healthcare resources. Surgical site infections are the result of a variety of reasons, which is why a range of prevention strategies have been proposed. Intraoperative wound irrigation (IOWI) is a simple procedure that involves moving a solution through an open wound to help hydrate the tissue. It is a type of prophylactic wound irrigation. It removes and dilutes bodily fluids, bacteria, and cellular debris. It may also act as a bactericidal agent when used with antibiotics and antiseptics. To evaluate the incidence of SSIin lumbar spine surgeries by comparing IOWI with normal saline containing gentamicin (NS-G) and normal saline (NS) alone. A hospital-based retrospective study was conducted among 40 patients who underwent elective lumbar spine surgery at the Department of Orthopaedics, RL Jalappa Hospital Centre, Kolar, Karnataka, India. Out of the total participants enrolled, 60% were males and 40% were females. There was no statistically significant difference found between mean age, mean BMI, mean hemoglobin level, mean WBC counts, and mean fasting blood sugar (FBS) levels among both groups. The overall prevalence of SSI among patients was 25%. In Group A (NS-G), the prevalence of SSI was 15%, and in Group B (NS), it was 35%. In total, 17.5% of study participants had superficial SSI, while 7.5% had deep SSI. Gentamicin, an aminoglycoside antibiotic, is bactericidal and efficient against gram-positive organisms likeStaphylococcus, the most frequent pathogen causing SSI in spine surgery. During lumbar spine surgery, IOWI with saline and gentamicin before closure is more effective in preventing SSI than simple saline irrigation.

Epidemiology of postoperative spinal wound infection in the Middle East and North Africa (MENA) region

BackgroundDespite the extensive literature on postoperative spinal wound infection, yet to our knowledge, there is no previous study containing combined data from several sites in the Middle East and North Africa (MENA) region. This study aimed to estimate the incidence of surgical site infection (SSI) following spine surgeries, its associated factors, and management. MethodsIn a retrospective cohort study, medical records of all patients ≥18 years of age who underwent spine surgery at 6 tertiary referral centers in the MENA region between January 2014 to December 2019 (n=5,872) were examined to collect data on the following: (1) Patient's characteristics, (2) Disease characteristics, (3) Spine surgery approach, and (4) Characteristics of Postoperative SSI. The determinants of postoperative SSI were identified using logistic regression analysis. Receiver operating characteristic (ROC) curve was applied to identify the cut-off of the length of stay in the hospital postoperatively till the infection is likely to occur. Significance was set at p<.05. ResultsThe overall incidence of SSI was 4.2% (95% CI: 3.72–4.77), in the form of deep (46.4%), superficial (43.1%), dehiscence (9.3%), and organ space (1.2%) infections. After adjusting for all possible confounders, significant predictors of postoperative SSI were; diabetes (OR=2.12, p<.001), smoking (OR=1.66, p=.002), revision surgery (OR=2.20, p<.001), open surgery (OR=2.73, p<.001), perioperative blood transfusion (OR=1.45, p=.033), ASA class III(OR=2.08, p=.002), and ≥4 days length of stay "LOS" (OR= 1.71, p=.001). A cut-off of 4 days was the optimum LOS above which postoperative SSI is more likely to occur, with 0.70 sensitivity, 0.47 specificity, and 0.61 area under the curve. ConclusionsThis is the first study that highlighted the incidence of postoperative SSI in spine surgery in the MENA region. Incidence figures are comparable to figures in different areas of the world. Identifying predictors of SSI might help high‑risk patients benefit from more intensive wound management.

Case Series of the Management of Surgical Site Infection following Thoracic Spinal Surgeries during COVID Pandemic

Introduction: Post-operative spinal wound infection increases the morbidity of the patient and the cost of healthcare. Despite the development of prophylactic antibiotics and advances in surgical technique and post-operative care, wound infection continues to compromise patient outcome after spinal surgery. This kind of infection places the patient at risk for pseudoarthrosis, adverse neurologic sequelae, chronic pain, deformity, and even death. In spite of all preventive measures, the SSI following spinal surgeries are 1% among operated spinal instrumentation. Case Series: Here, we present a series of three patients who presented to us with post-operative surgical site infection (SSI) in spine surgery in the form of wound, discharge, and other complaints. Out of all, two of them were operated with debridement and skin closure followed by broad spectrum IV antibiotics and one of them managed with vacuum-assisted closure dressing and high antibiotics sensitive to organisms found in wound culture. Optimization by building up hemoglobin, supplementing micronutrients including Vitamin C, D, and B12 and high protein diet was started as adjuvant therapy and all of them was discharged with healthy wound. Conclusion: SSI in spine surgery is a common but challenging complication, particularly after instrumental spinal arthrodesis. Using meticulous aseptic technique, intra-operative irrigation, prophylactic antibiotics, and optimizing patient factors preoperatively are key to preventing a SSI. In patients who still develop an infection despite efforts at prevention, timely diagnosis and treatment are critical. Instrumentation can be retained while still successfully clearing an early infection, although following fusion, instrumentation can be removed if lifetime oral antibiotic suppression is either not indicated or undesirable. Keywords: Spine surgery, Postoperative infections, Surgical site infection, Spinal instrumentation.

Preoperative Prevention of Surgical-Site Infection in Spine Surgery.

Surgical-site infections (SSI) contribute to increased hospital length of stay, readmission rates, cost, and morbidity and mortality rates. The spine service line at a suburban Level II trauma center encountered 2 SSIs among the spine fusion population within a 6-month period. This did not meet the organization's internal benchmark of zero. A pilot quasi-experimental design was used to determine whether preoperative cleansing with 2% chlorhexidine gluconate (CHG)-impregnated cloths versus current practice of bathing with 4% CHG solution would reduce SSIs. Infection rates were measured using simple percentages. Level of significance was p < .05. Outcome data showed a reduction in SSIs from 3.9% to 1.9% with use of 2% CHG-impregnated cloths. There was no significant difference found between the use of 2% CHG-impregnated cloths and 4% CHG solution (p = .524). This quality improvement change, combined with a strengthened preoperative bundle approach, has permanently been adopted within the spine service line. From October 2017 to March 2021, the spine service line has had zero SSIs within the spine fusion population.

Surgical Site Infection Prophylaxis and Wound Management in Spine Surgery.

Surgical site infection (SSI) is a potentially devastating complication of spinal surgery that increases patient morbidity and healthcare costs. SSIs have complex and multifactorial etiologies; therefore, there are numerous opportunities for prevention and risk mitigation. The aim of this narrative review was to describe the incidence, risk factors, and outcomes of SSIs in spine surgery with an emphasis on postoperative wound care. We list and describe the preoperative, intraoperative, and postoperative evidence-based interventions that can be applied to potentially prevent SSI after spinal surgery.

Risk factors for surgical site infection following spinal surgery in Saudi Arabia: A retrospective case-control study.

Surgical site infections (SSIs) are common complications after spinal surgery that result in increased morbidity, mortality, and healthcare costs. It was estimated that SSIs after spinal surgery resulted in a 4-fold increase in health care costs. The reported SSI rate following spinal surgery remains highly variable between approximately 0.5% and 18%. In this study, we aimed to estimate the SSI rate and identify possible risk factors for SSI after spinal surgery in our Saudi patient population.We conducted a single-center, retrospective case–control study in Saudi Arabia that included patients who developed SSIs, while the controls were all consecutive patients who underwent spinal surgery between January 2014 and December 2016. We extracted data on patient characteristics, anthropometric measurements, preoperative laboratory investigations, preoperative infection prevention measures, intraoperative measures, comorbidities, and postoperative care.We included 201 consecutive patients in our study; their median age was 56.9 years, and 51.2% were men. Only 4% (n = 8) of these patients developed SSIs postoperatively. Postoperative SSIs were significantly associated with longer postoperative hospital stays, hypertension, higher American Society of Anesthesia (ASA) scores, longer procedure durations, and the use of a greater number of blood transfusion units.This study revealed a low SSI rate following spinal surgery. We identified a history of hypertension, prolonged hospitalization, longer operative time, blood transfusion, and higher ASA score as risk factors for SSI in spine surgery in our population. As our findings are from a single institute, we believe that a national research collaboration among multiple disciplines should be performed to provide better estimates of SSI risk factors in our patient population.

244. Relationship between 25-hydroxy vitamin D level and surgical site infection in spine surgery

BACKGROUND CONTEXT Surgical site infection (SSI) creates a significant burden on the patient and the health care system. Preoperative medical optimization, antibiotics have been incorporated in standard practice reduce perioperative complications, and many others are currently under investigation. In animal models, 25-hydroxy vitamin D level has been shown to have antimicrobial and wound healing effects. Preoperative levels have been shown to correlate with SSI in thoracic and bariatric surgeries. However, to date it has not been evaluated in spine patients. PURPOSE To investigate whether low vitamin D status is associated with increased risk of developing post-operative infections in spine surgeries. STUDY DESIGN/SETTING Retrospective PATIENT SAMPLE Patients undergoing thoracolumbar spine surgery between November 2012 and March 2019 performed by one fellowship-trained orthopedic spine surgeon at a single academic center. OUTCOME MEASURES The outcome variable was SSI undergoing surgical intervention. METHODS We identified all patients within the stated sample and enrolled only patients with preop vitamin D levels. SSI, age, BMI, season of surgery, race, type of surgery, diagnosis, ASA, smoking status were extracted. The key independent variable was Vit D level (classified as 60 ng/mL= Potentially Harmful). Bivariate analysis with chi-square and t-tests were used to compare characteristics between the non-SSI and SSI cohorts undergoing spine surgery. Multivariable logistic regression analyses were used to determine associations between vitamin D levels and SSIs after controlling for relevant confounders such as BMI, type of surgery, diagnosis, comorbidities. RESULTS A total of 545 patients met our inclusion criteria, 9 (1.7%) of which acquired an SSI. The mean 25-Hydroxy vitamin D was 31.6 ± 13.6 ng/dL in non-SSI group, and 35.7 ± 20.2 ng/dL in SSI group (p-value 0.17). The mean age was 56 ± 15.6 years in the non-SSI group and 64 ± 7.5 years in the SSI group (p- value 0.045). 21.7% of non-SSI patients had moderate risk of vitamin D deficiency, 27.9% had low risk of deficiency, 46.8% had adequate levels and 3.6% had potentially harmful levels. 33.3% of non-SSI patients had moderate risk of Vitamin D deficiency, 11.1% had low risk of deficiency, 33.3% had adequate levels and 22.2% had potentially harmful levels (p-value 0.02). On bivariate analysis, the percentage of patients with potentially harmful levels of Vitamin D in the SSI group was higher than in the non-SSI group (22.2% and 3.6% respectively, p-value 0.02). On multivariable analysis, patients with adequate vitamin D level had lower odds of SSI as compared to vitamin D deficient patients (OR 0.11, CI 0.01-0.98, p-value 0.048). Though not statistically significant, patients with potentially harmful vitamin D level were at higher odds of SSI (OR 1.41, CI 0.11-17.34, p-value 0.79). CONCLUSIONS Our analysis showed that patients with adequate levels of vitamin D has lower risk of SSIs as compared to vitamin D deficient patients after controlling for relevant confounders. Optimizing preop vitamin D levels could potentially reduce the incidence of SSI in spine surgery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Spinal Fusion Surgery and Local Antibiotic Administration: A Systematic Review on Key Points From Preclinical and Clinical Data.

Systematic review. The present review of clinical and preclinical in vivo studies focused on the local antibiotic administration for surgical site infection (SSI) in spinal fusion procedures and identifying new approaches or research direction able to release antibiotics in the infected environment. SSI is a severe complication of spinal fusion procedures that represents a challenging issue for orthopedic surgeons. SSIs can range from 0.7% to 2.3% without instrumentation up to 6.7% with the use of instrumentation with significant implications in health care costs and patient management. A systematic search was carried out by two independent researchers according to the PRISMA statement in three databases (www.pubmed.com, www.scopus.com and www.webofknowledge.com) to identify preclinical in vivo and clinical reports in the last 10 years. Additionally, to evaluate ongoing clinical trials, three of the major clinical registry websites were also checked (www.clinicaltrials.gov, www.who.int/ictrp, https://www.clinicaltrialsregister.eu). After screening, a total of 43 articles were considered eligible for the review: 36 clinical studies and seven preclinical studies. In addition, six clinical trials were selected from the clinical registry websites. The results reported that the topical vancomycin application seem to represent a strategy to reduce SSI incidence in spine surgery. However, the use of local vancomycin as a preventive approach for SSIs in spine surgery is mostly based on retrospective studies with low levels of evidence and moderate/severe risk of bias that do not allow to draw a clear conclusion. This review also underlines that several key points concerning the local use of antibiotics in spinal fusion still remains to be defined to allow this field to make a leap forward that would lead to the identification of specific approaches to counteract the onset of SSIs. 4.

Application of Vancomycin Powder to Reduce Surgical Infection and Deep Surgical Infection in Spinal Surgery: A Meta-analysis.

This was a meta-analysis study. Our meta-analysis study aimed to evaluate the efficacy of vancomycin powder to reduce the surgical site infection (SSI) in spinal surgery. The SSI is a potential and devastating complication after spinal surgery. Local application of vancomycin powder is an attractive adjunctive therapy to reduce SSI in spinal surgery. Studies were identified from PubMed, The Cochrane Library, AMED, Web of Science, Scopus, Ovid, EMBASE, and Ebsco Medline. The fixed-effects model was used to compute the merge of relative risk and 95% confidence interval (CI). Heterogeneity tests were checked by I statistics. Subgroup analysis was performed to determine whether vancomycin powder was beneficial, that could reduce the SSI in spinal surgery, or not. Publication bias was explored by funnel plot. We included 21 studies for final analysis. In our analysis, application of vancomycin powder was associated with a significantly reduced risk of SSI and deep SSI. Pooled relative risks showed significant changes: SSI, 0.36 (95% CI: 0.27-0.47, P=0.000), SSI in the instrumented group, 0.35 (95% CI: 0.25-0.49, P=0.000), SSI in the noninstrumented group, 0.39 (95% CI: 0.24-0.65, P=0.000), deep SSI, 0.28 (95% CI: 0.18-0.44, P=0.000), and the incidence pseudoarthrosis, 0.88 (95% CI: 0.35-2.21, P=0.784). In the subgroup analysis, vancomycin powder showed beneficial effects to SSI in the instrumented group. Pooled the heterogeneity: SSI (P=0.124, I=30.0%), SSI in the instrumented group (P=0.366, I=8.2%), SSI in the noninstrumented group (P=0.039, I=60.5%), deep SSI (P=0.107, I=33.5%). The application of vancomycin powder could decrease the SSI and deep SSI in spinal surgery. In the subgroup, vancomycin powder is beneficial to the SSI in the instrumented group. The available evidence is too limited to make the conclusion that the use of vancomycin powder causes pseudoarthrosis in spinal surgery, its extrapolation should be carefully executed.

Current Strategies in Prevention of Postoperative Infections in Spine Surgery

Study Design:Narrative review.Objectives:Postoperative surgical site infections (SSIs) are among the most common acute complications in spine surgery and have a devastating impact on outcomes. They can lead to increased morbidity and mortality as well as greater economic burden. Hence, preventive strategies to reduce the rate of SSIs after spine surgery have become vitally important. The purpose of this article was to summarize and critically analyze the available evidence related to current strategies in the prevention of SSIs after spine surgery.Methods:A literature search utilizing Medline database was performed. Relevant studies from all the evidence levels have been included. Recommendations to decrease the risk of SSIs have been provided based on the results from studies with the highest level of evidence.Results:SSI prevention occurs at each phase of care including the preoperative, intraoperative, and postoperative periods. Meticulous patient selection, tight glycemic control in diabetics, smoking cessation, and screening/eradication of Staphylococcus aureus are some of the main preoperative patient-related preventive strategies. Currently used intraoperative measures include alcohol-based skin preparation, topical vancomycin powder, and betadine irrigation of the surgical site before closure. Postoperative infection prophylaxis can be performed by administration of silver-impregnated or vacuum dressings, extended intravenous antibiotics, and supplemental oxygen therapy.Conclusions:Although preventive strategies are already in use alone or in combination, further high-level research is required to prove their efficacy in reducing the rate of SSIs in spine surgery before evidence-based standard infection prophylaxis guidelines can be built.

Risk Factors and Prevention of Surgical Site Infections Following Spinal Procedures.

Study Design:Focused literature review.Objective:The objective of this article was to help identify potential risk factors as well as strategies to help prevent surgical site infections (SSIs) in spine surgery.Methods:An article search was performed using PubMed, EMBASE, and the Cochrane database of systematic reviews using the terms “surgery” OR “surgical” AND “spine” OR “spinal” AND “infection”. Systematic review articles, meta-analyses, and clinical trials with more than 100 patients were reviewed.Results:Both patient and perioperative factors contribute to the development of SSIs. Patient factors such as smoking, obesity, diabetes, Methicillin-resistant Staphylococcus aureus (MRSA) colonization, and malnutrition are all modifiable risk factors that can lead to SSIs. Procedural steps, including preoperative MRSA screening and treatment for colonization, preoperative antibiotics, skin preparation, minimizing operative time, antibiotic or betadine irrigation, avoiding personnel turnover, and postoperative wound care have also been shown to decrease infection rates.Conclusion:There are several measures a spine practitioner may be able to take in the preoperative, intraoperative, and postoperative settings. Protocols to counsel patients regarding modification of preexisting risk factors and ensure adequate antimicrobial therapy in the perioperative period may be developed to reduce SSIs in spine surgery.

Successful 6-Week Antibiotic Treatment for Early Surgical-site Infections in Spinal Surgery.

The incidence of spinal surgical site infections (SSIs) remains stable at less than 10%. Surgical reinterventions may be hampered by decubitus, treatment-related adverse events, and cost. In the context of emergence of bacterial resistance, a short duration of antimicrobial treatment is of critical importance. If the duration of treatment for SSI is currently 12 weeks, the aim of our study was to assess the efficacy of an antimicrobial treatment shortened to 6 weeks. This prospective study was carried out from November 2014 to July 2016 in an 827-bed teaching hospital. After surgical management of SSIs, patients received broad-spectrum antibiotics intravenously for 10 days and orally for the remainder, for a total of 6 weeks. Success was defined as absence of relapse, superinfection, or surgical failure at the end of treatment and at 1-year follow-up. Eighty-five patients were included in this study. The median delay between initial surgery and diagnosis of SSI was 16 days. In 65 cases (76.4%), SSIs were monomicrobial; among these, Staphylococcus aureus was found in 30 cases (46%). Failure was observed in 7 cases (8.2%), with more than half caused by anaerobic bacteria. Surgical management of SSI followed by a 6-week antibiotic treatment is associated with favorable outcome. Anaerobic bacteria seem to play a role in the occurrence of relapses. A 6-week reduction in antibiotic treatment leads to reduction in cost and, likely, also to reduction in the emergence and spread of resistant microorganisms.

Prospective Multicenter Surveillance Study of Surgical Site Infection after Spinal Surgery in Korea : A Preliminary Study.

ObjectiveThis study aimed to investigate the rates, types, and risk factors of surgical site infection (SSI) following spinal surgery using data from a Korean SSI surveillance system that included diagnoses made by surgeons. MethodsThis was a prospective observational study of patients who underwent spinal surgeries at 42 hospitals in South Korea from January 2017 to December 2017. The procedures included spinal fusion, laminectomy, discectomy, and corpectomy. Univariate and multivariate logistic regression analyses were performed. ResultsOf the 3080 cases included, 30 showed infection, and the overall SSI rate was 1.0% (an incidence of 1.2% in spinal fusion and 0.6% in laminectomy). Deep incisional infections were the most common type of SSIs (46.7%). Gram-positive bacteria caused 80% of the infections, and coagulase-negative staphylococci, including Staphylococcus epidermidis, accounted for 58% of the grampositive bacteria. A longer preoperative hospital stay was significantly associated with the incidence of SSI after both spinal fusion and laminectomy (p=0.013, p<0.001). A combined operation also was associated with SSI after laminectomy (p=0.032). ConclusionAn SSI surveillance system is important for the accurate analysis of SSI. The incidence of SSI after spinal surgery assessed by a national surveillance system was 1.0%. Additional data collection will be needed in future studies to analyze SSI in spinal surgery.

Topical Vancomycin in Pediatric Spine Surgery Does Not Reduce Surgical Site Infection: A Retrospective Cohort Study

Study DesignRetrospective cohort study. ObjectivesEvaluate the effectiveness of topical vancomycin in reducing surgical site infection (SSI) in pediatric patients undergoing posterior spinal fusion (PSF). Summary of Background DataThere has been increased interest in use of topical vancomycin to reduce SSI in spine surgery with mixed results reported in the literature. In Summer 2012, our institution implemented the use of topical vancomycin in definitive primary and revision PSF as part of our infection control protocol. MethodsAfter IRB approval, a consecutive series of 527 patients (538 procedures) undergoing PSF January 2010-December 2014 were retrospectively reviewed to identify the occurrence of SSI. Based on published results from a similar study, an a priori power analysis determined 190 patients were needed per group to achieve 0.90 power. In 228 procedures, topical vancomycin was used (Vanco) and in 310 procedures it was not (No Vanco). Exclusion criteria were <90 days follow-up, >18 years at time of surgery, and combined anterior and posterior fusion. Two-sample t tests, Wilcoxon rank-sum tests, and Fisher exact tests were used to compare the cohorts. ResultsGroups were similar in age, sex, implant density, fusion length, risk categorization, and surgical time (p > .05). No Vanco had significantly higher blood loss and incidence and amount of intraoperative allogenic transfusion (p < .001). Incidence of SSI was 3% (7/228) in Vanco and 2% (6/310) in No Vanco (p = .4099). Six of the 7 SSIs occurred in high-risk patients in Vanco and 5 of 6 occurred in high-risk patients in No Vanco (p = 1). Reoperation within 90 days was 6% (13/228) in Vanco and 4% (11/310) in No Vanco (p = .2912). Occurrence of other complications was similar between Vanco, 3% (7/228), and No Vanco, 2% (5/310). ConclusionUse of topical vancomycin did not reduce incidence of SSI for pediatric patients undergoing PSF at our institution. Level of EvidenceLevel III.

The combined administration of vancomycin IV, standard prophylactic antibiotics, and vancomycin powder in spinal instrumentation surgery: does the routine use affect infection rates and bacterial resistance?

Surgical site infections (SSI) poses significant risk following spinal instrumentation surgery. The 2013 North American Spine Society (NASS) Evidence-Based Clinical Guidelines found that the incidence of SSI in spine surgery ranged from 0.7-10%, with higher rates with medical comorbidities. National guidelines currently recommend first-generation cephalosporins as first line prophylaxis. Due to an increase in MRSA cases in our institution, a combined antibiotic strategy using vancomycin IV, standard prophylactic antibiotics, and vancomycin powder was implemented for all spinal instrumentation surgeries. All spinal instrumentation surgeries performed at this institution from 2013-2016 were identified. Chart review was then performed to identify the inclusion and exclusion criteria, demographic data, diagnosis, type of surgery performed, and bacterial culture results. Rates of SSI, as defined by the Center for Disease Control (CDC), were calculated and antibiotic resistance was determined. As control, SSIs were identified and reviewed from 2010, prior to the implementation of the combined strategy. One thousand and seventy four subjects were identified in the combined cohort. Mean age was 52.3 years, 540 males (50.2%), 534 females (49.8%). There were 960 primary surgeries (89.4%), 114 cases revision surgeries (10.6%). Cervical myelopathy (27.9%), lumbar stenosis (16.2%), lumbar spondylolisthesis (14.0%), and scoliosis (pediatric and adult)/deformity (13.7%) were leading diagnoses. The standard prophylactic antibiotic was cefazolin IV in 524 cases (48.8%), gentamicin IV in 526 cases (49.0%), vancomycin powder was used in 72.3% of cases. Four SSI cases out of 1,074 were identified (0.37%), 3 deep and 1 superficial, with no antibiotic resistance. In the control group, there were 11 infections of 892 cases (1.23%). There were significantly lower rates of SSI in the combined group versus control (P=0.05). The combined antibiotic strategy led to low SSI rates in this retrospective case control study. Limitations of this study include retrospective design and small sample size. A large multicenter randomized clinical trial may provide further insight in the effectiveness of this strategy. Level of evidence 3. Clinical relevance: the combined antibiotic protocol may be considered in institutions with concern for SSI and methicillin resistant infections associated with spinal instrumentation surgeries.

Relationship between preoperative serum rapid turnover proteins and early-stage surgical wound infection after spine surgery.

Malnutrition is one of the important risk factors for postoperative complications. Transferrin, prealbumin, and retinol-binding protein, so-called rapid turnover proteins (RTPs), may be the better indicators for early detection of nutritional deficits. However, few studies have described the impact of serum RTP levels on postoperative surgical site infection (SSI) in spine surgery. The purpose of this study was to investigate the relationship between preoperative serum RTPs and postoperative SSI. The data of 105 patients (64 male, 41 female; average age 64.4years; age range 20-88years) who underwent spine surgery in a single institution between 2014 and 2015 were retrospectively analyzed. Preoperative total lymphocyte count, serum albumin, transferrin, prealbumin, retinol-binding protein, pre-and postopeartive C-reactive protein (CRP), white blood cell count (WBC), and total lymphocyte count were evaluated. Postoperative CRP, WBC, and total lymphocyte count were repeated two or three times/week until hospital discharge. A broad spectrum penicillin or second generation cephalosporin was administered as a prophylactic antibiotic to each patient. When repeated CRP elevation or lymphopenia (no more than 10% or 1000/μL) after postoperative day 3 or 4 was observed, possible SSI was diagnosed. Variables between possible SSI group and non-SSI group were compared using Mann-Whitney U or Chi square test. All variables on univariate analysis were included in multiple logistic regression analysis to identify risk factors for possible postoperative SSI. Thirty-five patients were diagnosed with possible SSI. The mean operative time of possible SSI group was significantly longer (p=0.036), preoperative total lymphocyte count and serum prealbumin level of possible SSI group were significantly lower (p=0.002, p=0.048, respectively) than that of non-SSI group. On univariate analysis, operative time (p=0.012), preoperative total lymphocyte count (p=0.041), serum albumin level (p=0.038), and serum prealbumin level (p=0.044) were significant contributors to possible SSI, and multiple logistic regression analysis revealed that operative time was the significant contributor to possible SSI (odds ratio 1.008, 95% confidence interval (CI) 1.001-1.015, p=0.024). A low prealbumin level is a possible risk factor for early-stage SSI in spine surgery, though it was not statistically significant; operative time was the most important indicator of SSI on multivariate analysis.

Postoperative Spine Infections.

Postoperative spinal wound infection increases the morbidity of the patient and the cost of healthcare. Despite the development of prophylactic antibiotics and advances in surgical technique and postoperative care, wound infection continues to compromise patient outcome after spinal surgery. Spinal instrumentation also has an important role in the development of postoperative infections. This review analyses the risk factors that influence the development of postoperative infection. Classification and diagnosis of postoperative spinal infection is also discussed to facilitate the choice of treatment on the basis of infection severity. Preventive measures to avoid surgical site (SS) infection in spine surgery and methods for reduction of all the changeable risk factors are discussed in brief. Management protocols to manage SS infections in spine surgery are also reviewed.

Surgical Site Infections in Pediatric Spine Surgery: Comparative Microbiology of Patients with Idiopathic and Nonidiopathic Etiologies of Spine Deformity.

Surgical site infections (SSIs) are a concern in pediatric spine surgery with unusually high rates for a clean surgery and especially for patients with deformity of nonidiopathic etiology. Microbiologic differences between etiologies of spine deformities have been poorly investigated. We reviewed all cases of SSI in spinal surgery between 2007 and 2011. Characteristics of cases and of bacteria according to the etiology of the spine disease were investigated. Of 496 surgeries, we identified 51 SSIs (10.3%) in 49 patients. Staphylococcus aureus was the most frequent pathogen whatever the etiology (n = 31, 61% of infection cases). The second most frequent pathogens vary according to the etiology of the spine deformity. It was Gram-negative bacilli (GNB) in nonidiopathic cases (n = 19, 45% of cases) and anaerobe in idiopathic cases (n = 8, 38% of cases), particularly Gram-positive anaerobic cocci (n = 5, 24% of cases). Infection rate was 6.8% in cases with idiopathic spine disease (n = 21) and 15.9% in cases with nonidiopathic spine disease (n = 30). Nonidiopathic cases were more frequently male with lower weight. American Society of Anesthesiologists score was more often greater than 2, they had more frequently sacral implants and postoperative intensive care unit stay. GNB were significantly associated with a nonidiopathic etiology, low weight, younger age and sacral fusion. SSIs were polymicrobial in 31% of cases with a mean of 1.4 species per infection cases. S. aureus is the first cause of SSI in pediatric spine surgery. However, Gram-positive anaerobic cocci should be taken into account in idiopathic patients and GNB in nonidiopathic patients when considering antibiotic prophylaxis and curative treatment.