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Zhang H, Zhao Y, Du Y, Yang Y, Zhang J, Wang S. Optimal time window for initiating cefuroxime surgical antimicrobial prophylaxis in spinal fusion surgery: a nested case-control study. Spine J 2024; 24:961-968. [PMID: 38301900 DOI: 10.1016/j.spinee.2024.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 01/22/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND CONTEXT Surgical site infections (SSI) are one of the common complications following spinal fusion surgery. Unfortunately, several studies had shown conflicting results regarding optimal timing of surgical antimicrobial prophylaxis (SAP) administration. Due to limitations in population homogeneity and sample size, these studies have not provided significant statistical correlations or clear practical recommendations. PURPOSE The purpose of the study was to investigate the impact of timing of cefuroxime SAP on the risk of SSI in patients undergoing spinal fusion surgery, and to determine the optimal timing of administration. DESIGN Retrospective nested case-control study. PATIENT SAMPLE We retrospectively analyzed consecutive patients who underwent spinal fusion surgery at our institution between October 2011 and October 2021. OUTCOME MEASURE In the current study, the primary outcome measure was SSI. METHODS This was a retrospective nested case-control study. All consecutive patients who underwent spinal fusion surgery at our institution between October 2011 and October 2021 formed a retrospective cohort. For each SSI case, 2 controls free of SSI at the time of the index date of their corresponding case were selected, matched by age, sex, and calendar year. Electronic record and radiographic data were reviewed retrospectively in electronic database. SAP related data included timing of administration, preoperative dose, intraoperative second dose, and postoperative use. To examine the effects of mismatched variables, we further adjusted for possible confounding factors using conditional logistic regression models. Subsequently, subgroup analyses were conducted to assess the robustness of the statistical associations. RESULTS According to the preplanned statistical scheme and matching factors, we matched 236 controls for these SSI cases, and the subsequent statistical analysis was performed on these 354 patients. After adjusting for confounding factors, the results indicated that the risk of SSI was 70% higher in the group receiving SAP 31 to 60 minutes before incision compared to the group receiving SAP 0 to 30 minutes before incision (OR=1.732, 95%CI 1.031-2.910, p=.038). Additionally, the risk of SSI was 150% higher in the group receiving SAP 61 to 120 minutes before incision compared to the group receiving SAP 0 to 30 minutes before incision (OR=2.532, 95%CI 1.250-5.128, p=.010). In subgroup analysis, this statistical trend persisted for both deformity surgeries and different SSI classifications. CONCLUSION Administering cefuroxime SAP within 30 minutes before skin incision significantly reduces the risk of SSI, whether they are deep or superficial, in spinal fusion surgery. This pattern remains consistent among spinal deformity patients.
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Affiliation(s)
- Haoran Zhang
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1st Shuai Fu Yuan, Dongcheng District, Beijing, China
| | - Yiwei Zhao
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1st Shuai Fu Yuan, Dongcheng District, Beijing, China
| | - You Du
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1st Shuai Fu Yuan, Dongcheng District, Beijing, China
| | - Yang Yang
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1st Shuai Fu Yuan, Dongcheng District, Beijing, China
| | - Jianguo Zhang
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1st Shuai Fu Yuan, Dongcheng District, Beijing, China
| | - Shengru Wang
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1st Shuai Fu Yuan, Dongcheng District, Beijing, China.
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Watanabe K, Yamaguchi T, Suzuki S, Suzuki T, Nakayama K, Demura S, Taniguchi Y, Yamamoto T, Sugawara R, Sato T, Fujiwara K, Murakami H, Akazawa T, Kakutani K, Hirano T, Yanagida H, Watanabe K, Matsumoto M, Uno K, Kotani T, Takeshita K, Ohara T, Kawakami N. Surgical Site Infection Following Primary Definitive Fusion for Pediatric Spinal Deformity: A Multicenter Study of Rates, Risk Factors, and Pathogens. Spine (Phila Pa 1976) 2021; 46:1097-1104. [PMID: 33496537 DOI: 10.1097/brs.0000000000003960] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective multicenter study. OBJECTIVE To determine the surgical site infection (SSI) rate, associated risk factors, and causative pathogens in pediatric patients with spinal deformity. SUMMARY OF BACKGROUND DATA There have been no extensive investigations of the risk factors for SSI in Japan. METHODS Demographic data, radiographic findings, and the incidence of SSI were retrospectively analyzed in 1449 pediatric patients who underwent primary definitive fusion surgery for spinal deformity at any of 15 institutions from 2015 to 2017. SSI was defined according to the US Centers for Disease Control and Prevention guideline. RESULTS The incidence of all SSIs was 1.4% and that of deep SSIs was 0.76%. The most common pathogenic microbes were methicillin-resistant staphylococci (n = 5) followed by gram-negative rods (n = 4), methicillin-sensitive staphylococci (n = 1), and others (n = 10). In univariate analysis, younger age, male sex, a diagnosis of kyphosis, type of scoliosis, American Society of Anesthesiologists (ASA) class ≥3, mental retardation urinary incontinence, combined anterior-posterior fusion, greater magnitude of kyphosis, three-column osteotomy, use of blood transfusion, and number of antibiotic administration were associated with the likelihood of SSI (all P < 0.05). Multivariate logistic regression analysis identified the following independent risk factors for SSI: syndromic scoliosis etiology (vs. idiopathic scoliosis; adjusted odds ratio [OR] 16.106; 95% confidence interval [CI] 2.225-116.602), neuromuscular scoliosis etiology (vs. idiopathic scoliosis; adjusted OR 11.814; 95% CI 1.109-125.805), ASA class 3 (vs. class 2; adjusted OR 15.231; 95% CI 1.201-193.178), and administration of antibiotic therapy twice daily (vs. three times daily; adjusted OR 6.121; 95% CI 1.261-29.718). CONCLUSION The overall infection rate was low. The most common causative bacteria were methicillin-resistant followed by gram-negative rods. Independent risk factors for SSI in pediatric patients undergoing spinal deformity surgery were scoliosis etiology, ASA class 3, and administration of antibiotic therapy twice daily.Level of Evidence: 3.
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Affiliation(s)
- Kei Watanabe
- Department of Orthopaedic Surgery, Niigata University School of Medicine, Niigata City, Niigata, Japan
| | - Toru Yamaguchi
- Department of Orthopaedic Surgery, Fukuoka Children's Hospital, Higashi-ku, Fukuoka City, Fukuoka, Japan
| | - Satoshi Suzuki
- Department of Orthopaedic Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Teppei Suzuki
- Department of Orthopaedic Surgery, National Hospital Organization Kobe Medical Center, Suma-ku, Kobe City, Hyogo, Japan
| | - Keita Nakayama
- Department of Orthopaedic Surgery, Seirei Sakura Citizen Hospital, Sakura City, Chiba, Japan
| | - Satoru Demura
- Department of Orthopaedic Surgery, Kanazawa University School of Medicine, Kanazawa City, Ishikawa, Japan
| | - Yuki Taniguchi
- Department of Orthopaedic Surgery, Tokyo University School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Takuya Yamamoto
- Department of Orthopaedic Surgery, Red Cross Kagoshima Hospital, Kagoshima City, Kagoshima, Japan
| | - Ryo Sugawara
- Department of Orthopaedic Surgery, Jichi Medical University School of Medicine, Shimotsuke City, Tochigi, Japan
| | - Tatsuya Sato
- Department of Orthopaedic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Kenta Fujiwara
- Department of Orthopaedic Surgery, Osaka Medical College School of Medicine, Takatsuki City, Osaka, Japan
| | - Hideki Murakami
- Department of Orthopaedic Surgery, Iwate Medical University School of Medicine, Morioka City, Iwate, Japan
| | - Tsutomu Akazawa
- Department of Orthopaedic Surgery, St Marianna University School of Medicine, Miyamae-ku, Kawasaki City, Kanagawa, Japan
| | - Kenichiro Kakutani
- Department of Orthopaedic Surgery, Kobe University School of Medicine, chuou-ku, Kobe City, Hyogo, Japan
| | - Toru Hirano
- Department of Orthopaedic Surgery, Niigata University School of Medicine, Niigata City, Niigata, Japan
| | - Haruhisa Yanagida
- Department of Orthopaedic Surgery, Fukuoka Children's Hospital, Higashi-ku, Fukuoka City, Fukuoka, Japan
| | - Kota Watanabe
- Department of Orthopaedic Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Morio Matsumoto
- Department of Orthopaedic Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Koki Uno
- Department of Orthopaedic Surgery, National Hospital Organization Kobe Medical Center, Suma-ku, Kobe City, Hyogo, Japan
| | - Toshiaki Kotani
- Department of Orthopaedic Surgery, Seirei Sakura Citizen Hospital, Sakura City, Chiba, Japan
| | - Katsushi Takeshita
- Department of Orthopaedic Surgery, Jichi Medical University School of Medicine, Shimotsuke City, Tochigi, Japan
| | - Tetsuya Ohara
- Department of Orthopaedic Surgery, Meijo Hospital, Naka-ku, Nagoya City, Aichi, Japan
| | - Noriaki Kawakami
- Department of Orthopaedic Surgery, Meijo Hospital, Naka-ku, Nagoya City, Aichi, Japan
- Department of Orthopaedic Surgery, Ichinomiyanishi Hospital, Ichinomiya City, Aichi, Japan
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Prevention of surgical site infections in pediatric spines: a single-center experience. Childs Nerv Syst 2021; 37:2299-2304. [PMID: 33635418 DOI: 10.1007/s00381-021-05095-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 02/17/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE To describe the potential issues in the methodology of surgical site infection (SSI) prevention and how it was investigated and corrected in a single institution. METHODS A pediatric orthopedic unit experienced an increase of SSI, concerning up to 10% of scoliosis surgery cases from 2011 to 2013. An institutional procedure of multimodal and interdisciplinary risk evaluation was initiated, including a review of the literature, a morbi-mortality meeting, internal and external audits concerning the hygiene conditions in the operating room, the antibiotic prophylaxis, patients, and sterile material pathways. Several preventive actions were implemented, including the improvement of air treatment in the operating room, wound irrigation with 2L of saline before closure, application of topic vancomycine in the wound, verification of doses and timing of antibiotics injection, and use of waterproof bandages. We compared the rates of spine SSI before (retrospective group, 2011-2013) and after the implementation of various preventive measures (prospective group, 2014-2018). RESULTS SSI occurred in 12 patients (6 idiopathic and 6 neuromuscular) out of 120 operated on (93 idiopathic, 18 neuromuscular, 9 others) in the retrospective group and 2 (both neuromuscular) out of 196 (150 idiopathic, 33 neuromuscular,13 others) in the prospective group (10% vs 1%, odds ratio=9.7, p=0.001). The groups were comparable for age, etiology, duration of surgery, body mass index, American Society of Anesthesiologists score, number of levels fused, and blood loss (p>0.2). CONCLUSION The systematic analysis of SSI allowed for the understanding of the failures and correcting them. The current process is effectively preventing SSI. LEVEL OF EVIDENCE 3: prospective series with case-control analysis.
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Cahill PJ, Mahmoud MA, MacAlpine EM, Tatad AM, Campbell RM, Flynn JM. Correlation between surgical site infection and classification of early onset scoliosis (C-EOS) in patients managed by rib-based distraction instrumentation. Spine Deform 2020; 8:787-792. [PMID: 32232746 DOI: 10.1007/s43390-020-00103-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 03/09/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The aim of this study is to determine risk factors for infection among EOS patients treated by rib-based distraction instrumentation, and to further assess the incidence of infection among C-EOS categories and sub-types. Despite the heterogonous nature of early onset scoliosis, the classification of early onset scoliosis (C-EOS) has proven to have excellent reliability across its major categories. C-EOS's reliability has been verified; however, little data exist on the utility of this categorization in clinical decision-making and risk assessment. METHODS After institutional review board approval, data for EOS patients treated by rib-based distraction instrumentation were collected between 2013 and 2017 in a single institution. Data collection included: major categories of early onset scoliosis classification (etiology, major curve and kyphosis), BMI, height, weight, procedure type, site of procedure, presence of tracheostomy, and bowel/urinary incontinence. RESULTS 156 EOS patients underwent 843 rib-based distraction instrumentation procedures. 22.4% of patients (35/156 patients, 42 procedures) developed infections, 30/35 requiring irrigation and debridement. Type of procedure was significantly associated with infection rate, with rib-based distraction instrumentation insertion corresponding with the highest incidence of infection, as compared to instrumentation revisions or expansions (p = 0.006). Infection rates were also more common in shorter and lighter weight children (p = 0.001 and 0.03; respectively). Patients with a neuromuscular etiology had the highest rate of infection in comparison to congenital, syndromic, and idiopathic (5.7% vs, 4.9%, 4.7%, and 2.6%; respectively). Notably, high infection rates occurred neuromuscular hyper-kyphotic subjects (M+), occurring in all major curve C-EOS subgroups and at a rate of 8.3% for all procedures. CONCLUSION Neuromuscular, larger magnitude major curve, and larger magnitude kyphotic angle C-EOS categories appear to be at a higher risk of infection. Such information potentiates the usefulness of C-EOS in surgical decision-making and in the informed consent process. LEVEL OF EVIDENCE Level III therapeutic.
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Affiliation(s)
- Patrick J Cahill
- Division of Orthopaedics, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Mahmoud A Mahmoud
- Division of Orthopaedics, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Elle M MacAlpine
- Division of Orthopaedics, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Aaron M Tatad
- Division of Orthopaedics, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Robert M Campbell
- Division of Orthopaedics, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - John M Flynn
- Division of Orthopaedics, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
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Kwan KYH, Koh HY, Blanke KM, Cheung KMC. Complications following surgery for adolescent idiopathic scoliosis over a 13-year period. Bone Joint J 2020; 102-B:519-523. [PMID: 32228070 DOI: 10.1302/0301-620x.102b4.bjj-2019-1371.r1] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The purpose of this study was to evaluate the incidence and analyze the trends of surgeon-reported complications following surgery for adolescent idiopathic scoliosis (AIS) over a 13-year period from the Scoliosis Research Society (SRS) Morbidity and Mortality database. METHODS All patients with AIS between ten and 18 years of age, entered into the SRS Morbidity and Mortality database between 2004 and 2016, were analyzed. All perioperative complications were evaluated for correlations with associated factors. Complication trends were analyzed by comparing the cohorts between 2004 to 2007 and 2013 to 2016. RESULTS Between 2004 and 2016, a total of 84,320 patients were entered into the database. There were 1,268 patients associated with complications, giving an overall complication rate of 1.5%. Death occurred in 12 patients (0.014%). The three most commonly reported complications were surgical site infection (SSI) (441 patients; 0.52%), new neurological deficit (293; 0.35%), and implant-related complications (172; 0.20%). There was a statistically significant but weak correlation between the occurrence of a SSI and the magnitude of the primary curve (r = 0.227; p < 0.001), and blood loss in surgery (r = 0.111; p = 0.038), while the occurrence of a new neurological deficit was correlated statistically significantly but weakly with age at surgery (r = 0.147; p = 0.004) and magnitude of the primary curve (r = 0.258; p < 0.001). The overall complication rate decreased from 4.95% during 2004 to 2007 to 0.98% during 2013 to 2016 (p = 0.023). CONCLUSION An overall complication rate of 1.5% was found in our series after surgery for AIS, with a reduction of complication rates found in the second period of the analysis. Cite this article: Bone Joint J 2020;102-B(4):519-523.
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Affiliation(s)
- Kenny Y H Kwan
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | - Hui Y Koh
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | | | - Kenneth M C Cheung
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
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Garg S, Khechoyan D, Kim EB, French B. Multilayered and Flap Closure Technique for Pediatric Spinal Deformity Surgery. J Am Acad Orthop Surg 2020; 28:e92-e99. [PMID: 31977607 DOI: 10.5435/jaaos-d-18-00601] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Wound complications after pediatric spinal deformity surgery are a relatively common and challenging complication that results in emotional, physical, and monetary costs to the patients, families, and healthcare providers. The role of wound closure techniques for the prevention of wound complications is being increasingly explored. Interdisciplinary care by spinal surgeons and plastic surgeons has been recently found to decrease wound complication rates in patients with nonidiopathic scoliosis.
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Affiliation(s)
- Sumeet Garg
- From the Pediatric Orthopaedics and Spine Surgery (Dr. Garg), Children's Hospital Colorado, the Pediatric Plastic and Reconstructive Surgery (Dr. Khechoyan and Dr. French), Children's Hospital Colorado, and the Musculoskeletal Research Center (Kim), Children's Hospital Colorado, Aurora, CO
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Increased acute postoperative wound problems following spinal fusion in overweight patients with adolescent idiopathic scoliosis. J Pediatr Orthop B 2019; 28:374-379. [PMID: 30768579 DOI: 10.1097/bpb.0000000000000610] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
This study assessed the rate of adverse wound events in individuals with adolescent idiopathic scoliosis who underwent a posterior spinal fusion and sought to determine if obesity was related to the rate of adverse wound events. A retrospective review of patients with adolescent idiopathic scoliosis that underwent posterior spinal fusion between 2001 and 2013 was performed. Preoperative, perioperative, and postoperative data, including wound adverse events, were obtained through medical record review. Using the Center for Disease Control BMI criteria, participants were grouped into overweight/obese (BMI%≥85 percentile) or healthy/underweight (BMI%<85 percentile) groups. Obesity and prolonged hospital stay were independent risk factors for increased risk of wound problems.
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