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Ferrer Pomares P, Duque Santana P, Moreno Mateo F, Mengis Palleck CL, Tomé Bermejo F, Álvarez Galovich L. Comparison of Surgical Site Infection After Instrumented Spine Surgery in Patients With High Risk of Infection According to Different Antibiotic Prophylaxis Protocols: A Cohort Study of 132 Patients With a Minimum Follow-Up of 1 year. Global Spine J 2024:21925682241270097. [PMID: 39089872 DOI: 10.1177/21925682241270097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/04/2024] Open
Abstract
STUDY DESIGN Observational Study. OBJECTIVES Surgical site infections (SSIs) are one of the major complications in spine surgery. Numerous factors that increase the risk of SSI have been widely described. However, clinical guidelines on antibiotic prophylaxis are usually common for all patients. There are no specific guidelines for patients with a high risk of infection. The aim of this paper is to create a specific protocol for patients at high risk of SSI. METHODS This is a three-cohort study using a prospective database. Risk patients are those who meet at least two of the following criteria: obesity, diabetes, reoperation and immunosuppression. Between October 2021 and April 2023, 132 patients were recruited.They were divided into three cohorts: cohort A, 46 patients, standard prophylaxis with cefazolin 2 g/8 h for 24 h; cohort B, 46 patients, cefazolin 2 g/8h and amikacin 500 mg/12 h for 24 h; cohort C, 40 patients, cefazolin 2 g/8h and amikacin 500 mg/12 h for 72 h. RESULTS There was a significant decrease in the infection rate depending on the prophylaxis (23.9% in cohort A, 8.7% in cohort B, and 2.5% in cohort C). When logistic regression models were applied and cohorts B and C were compared with A, the following results were obtained: OR of 0.30 (CI: 0.08 - 0.97; P = 0.057) and 0.08 (IC: 0.00 - 0.45; P = 0.019), respectively. CONCLUSIONS Prophylaxis with prolonged double antibiotic therapy with cefazolin and amikacin is associated with a statistically significant decrease in the rate of SSI in patients with a high risk of infection.
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Affiliation(s)
| | - Pablo Duque Santana
- Spinal Conditions Unit, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | | | | | - Felix Tomé Bermejo
- Department of Orthopaedic and Trauma Surgery, General University Hospital of Villalba, Madrid, Spain
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Chehrassan M, Nikouei F, Shakeri M, Behnamnia A, Mahabadi EA, Ghandhari H. The role of environmental and seasonal factors in spine deep surgical site infection: the air pollution, a factor that may be underestimated. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:3148-3153. [PMID: 38461454 DOI: 10.1007/s00586-024-08183-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 12/13/2023] [Accepted: 02/04/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Different strategies have been described in order to reduce spine deep surgical site infection (SSI); however, non-intervenable items such as environmental factors remain as one of the main concerns for spine surgeons. METHODS A retrospective cohort study was designed in order to evaluate the effect of environmental factors such as temperature, humidity and particularly the air pollution index (PM 2.5) on spine surgical site infection. The files of 3609 patients who underwent spinal surgery from April 2019 to March 2022 were reviewed, and 121 patients with spine SSI were detected. RESULTS There was no significant relationship between mean temperature and humidity of each month with infection and type of bacteria. However, there was a significant relation between warmer season periods and infection. The rate of infection among patients was 3.25% ranged from 2.5% to 4% in colder and warmer seasons accordingly. It was determined that air pollution had a significant relationship with the infection and the type of bacteria. (p value < 0.05, R-Squared = 0.249). CONCLUSIONS Our study revealed a 60% increase in spine SSI during warmer seasons. There was a significant correlation between air pollution and the rate of infection. These may suggest the necessity to reduce the number of elective spine surgeries during warmer seasons and when the level of air pollutant is high.
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Affiliation(s)
- Mohammadreza Chehrassan
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran.
| | - Farshad Nikouei
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
- Department of Orthopedic, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Shakeri
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
- Department of Orthopedic, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Abolfazl Behnamnia
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
- Department of Orthopedic, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Ebrahim Ameri Mahabadi
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
- Department of Orthopedic, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Hasan Ghandhari
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
- Department of Orthopedic, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
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Zaidat B, Shrestha N, Rosenberg AM, Ahmed W, Rajjoub R, Hoang T, Mejia MR, Duey AH, Tang JE, Kim JS, Cho SK. Performance of a Large Language Model in the Generation of Clinical Guidelines for Antibiotic Prophylaxis in Spine Surgery. Neurospine 2024; 21:128-146. [PMID: 38569639 PMCID: PMC10992653 DOI: 10.14245/ns.2347310.655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/29/2024] [Accepted: 02/17/2024] [Indexed: 04/05/2024] Open
Abstract
OBJECTIVE Large language models, such as chat generative pre-trained transformer (ChatGPT), have great potential for streamlining medical processes and assisting physicians in clinical decision-making. This study aimed to assess the potential of ChatGPT's 2 models (GPT-3.5 and GPT-4.0) to support clinical decision-making by comparing its responses for antibiotic prophylaxis in spine surgery to accepted clinical guidelines. METHODS ChatGPT models were prompted with questions from the North American Spine Society (NASS) Evidence-based Clinical Guidelines for Multidisciplinary Spine Care for Antibiotic Prophylaxis in Spine Surgery (2013). Its responses were then compared and assessed for accuracy. RESULTS Of the 16 NASS guideline questions concerning antibiotic prophylaxis, 10 responses (62.5%) were accurate in ChatGPT's GPT-3.5 model and 13 (81%) were accurate in GPT-4.0. Twenty-five percent of GPT-3.5 answers were deemed as overly confident while 62.5% of GPT-4.0 answers directly used the NASS guideline as evidence for its response. CONCLUSION ChatGPT demonstrated an impressive ability to accurately answer clinical questions. GPT-3.5 model's performance was limited by its tendency to give overly confident responses and its inability to identify the most significant elements in its responses. GPT-4.0 model's responses had higher accuracy and cited the NASS guideline as direct evidence many times. While GPT-4.0 is still far from perfect, it has shown an exceptional ability to extract the most relevant research available compared to GPT-3.5. Thus, while ChatGPT has shown far-reaching potential, scrutiny should still be exercised regarding its clinical use at this time.
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Affiliation(s)
- Bashar Zaidat
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nancy Shrestha
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ashley M. Rosenberg
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Wasil Ahmed
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rami Rajjoub
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Timothy Hoang
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mateo Restrepo Mejia
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Akiro H. Duey
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Justin E. Tang
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jun S. Kim
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel K. Cho
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Barfield RK, Brown ML, Albrecht B, Barber KE, Bouchard J, Carr AL, Chahine EB, Cluck D, Covington EW, Deri CR, Durham SH, Faulkner-Fennell C, Freeman LK, Gauthier TP, Gibson GM, Green SB, Hobbs ALV, Jones BM, Jozefczyk CC, Marx AH, McGee EU, McKamey LJ, Musgrove R, Perez E, Slain D, Stover KR, Turner MS, White C, Bookstaver PB, Bland CM. A Baker's Dozen of Top Antimicrobial Stewardship Intervention Publications in 2022. Open Forum Infect Dis 2024; 11:ofad687. [PMID: 38434614 PMCID: PMC10906711 DOI: 10.1093/ofid/ofad687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 01/02/2024] [Indexed: 03/05/2024] Open
Abstract
Keeping abreast of the antimicrobial stewardship-related articles published each year is challenging. The Southeastern Research Group Endeavor identified antimicrobial stewardship-related, peer-reviewed literature that detailed an actionable intervention during 2022. The top 13 publications were selected using a modified Delphi technique. These manuscripts were reviewed to highlight actionable interventions used by antimicrobial stewardship programs to capture potentially effective strategies for local implementation.
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Affiliation(s)
- Reagan K Barfield
- Department of Pharmacy, University of South Carolina College of Pharmacy, Columbia, South Carolina, USA
| | - Matthew L Brown
- Department of Pharmacy, UAB Hospital, Birmingham, Alabama, USA
| | - Benjamin Albrecht
- Department of Pharmacy, Emory University Hospital, Atlanta, Georgia, USA
| | - Katie E Barber
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, Mississippi, USA
| | - Jeannette Bouchard
- Liaison Clinical Pharmacist, Duke Antimicrobial Stewardship Outreach Network (DASON), Durham, North Carolina, USA
| | - Amy L Carr
- Department of Pharmacy, AdventHealth Orlando, Orlando, Florida, USA
| | - Elias B Chahine
- Department of Pharmacy Practice, Palm Beach Atlantic University Gregory School of Pharmacy, West Palm Beach, Florida, USA
| | - David Cluck
- Department of Pharmacy Practice, East Tennessee State University—Gatton College of Pharmacy, Johnson City, Tennessee, USA
| | - Elizabeth W Covington
- Department of Pharmacy Practice, Auburn University Harrison College of Pharmacy, Auburn, Alabama, USA
| | - Connor R Deri
- Department of Pharmacy, Duke University Hospital, Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Spencer H Durham
- Department of Pharmacy Practice, Auburn University Harrison College of Pharmacy, Auburn, Alabama, USA
| | | | - Lauren K Freeman
- Department of Pharmacy, McLeod Regional Medical Center, Florence, South Carolina, USA
| | - Timothy P Gauthier
- Clinical Pharmacy Enterprise, Baptist Health South Florida, Miami, Florida, USA
| | - Geneen M Gibson
- Department of Pharmacy, St. Joseph's/Candler Health System, Savannah, Georgia, USA
| | - Sarah B Green
- Department of Pharmacy, Emory University Hospital, Atlanta, Georgia, USA
| | | | - Bruce M Jones
- Department of Pharmacy, St. Joseph's/Candler Health System, Savannah, Georgia, USA
| | - Caroline C Jozefczyk
- Department of Pharmacy, Prisma Health Greenville Memorial Hospital, Greenville, South Carolina, USA
| | - Ashley H Marx
- Department of Pharmacy, UNC Medical Center, Chapel Hill, North Carolina, USA
| | - Edoabasi U McGee
- Department of Pharmacy Practice, Philadelphia College of Osteopathic Medicine, School of Pharmacy, GA Campus, Suwanee, Georgia, USA
| | - Lacie J McKamey
- System Pharmacy, Novant Health, Charlotte, North Carolina, USA
| | - Rachel Musgrove
- Department of Pharmacy, St. Joseph's/Candler Health System, Savannah, Georgia, USA
| | - Emily Perez
- Department of Pharmacy, ECU Health Medical Center, Greenville, North Carolina, USA
| | - Douglas Slain
- School of Pharmacy and Section of Infectious Diseases, West Virginia University, Morgantown, West Virginia, USA
| | - Kayla R Stover
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, Mississippi, USA
| | - Michelle S Turner
- Department of Pharmacy, Cone Health, Greensboro, North Carolina, USA
| | - Cyle White
- Department of Pharmacy, Erlanger Health System, Chattanooga, Tennessee, USA
| | - P Brandon Bookstaver
- Department of Pharmacy, University of South Carolina College of Pharmacy, Columbia, South Carolina, USA
| | - Christopher M Bland
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Savannah, Georgia, USA
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Ahmed NJ, Haseeb A, AlQarni A, AlGethamy M, Mahrous AJ, Alshehri AM, Alahmari AK, Almarzoky Abuhussain SS, Mohammed Ashraf Bashawri A, Khan AH. Antibiotics for preventing infection at the surgical site: Single dose vs. multiple doses. Saudi Pharm J 2023; 31:101800. [PMID: 38028220 PMCID: PMC10661588 DOI: 10.1016/j.jsps.2023.101800] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 09/21/2023] [Indexed: 12/01/2023] Open
Abstract
Background Surgical site infections are common and expensive infections that can cause fatalities or poor patient outcomes. To prevent these infections, antibiotic prophylaxis is used. However, excessive antibiotic use is related to higher costs and the emergence of antimicrobial resistance. Objectives The present meta-analysis aimed to compare the effectiveness of a single dosage versus several doses of antibiotics in preventing the development of surgical site infections. Methods PubMed was used to find clinical trials evaluating the effectiveness of a single dosage versus several doses of antibiotics in avoiding the development of surgical site infections. The study included trials that were published between 1984 and 2022. Seventy-four clinical trials were included in the analysis. Odds ratios were used to compare groups with 95% confidence intervals. The data were displayed using OR to generate a forest plot. Review Manager (RevMan version 5.4) was used to do the meta-analysis. Results Regarding clean operations, there were 389 surgical site infections out of 5,634 patients in a single dose group (6.90%) and 349 surgical site infections out of 5,621 patients in multiple doses group (6.21%) (OR = 1.11, lower CI = 0.95, upper CI = 1.30). Regarding clean-contaminated operations, there were 137 surgical site infections out of 2,715 patients in a single dose group (5.05%) and 137 surgical site infections out of 2,355 patients in multiple doses group (5.82%) (OR = 0.87, lower CI = 0.68, upper CI = 1.11). Regarding contaminated operations, there were 302 surgical site infections out of 3,262 patients in a single dose group (9.26%) and 276 surgical site infections out of 3,212 patients in multiple doses group (8.59%) (OR = 1.11, lower CI = 0.84, upper CI = 1.47). In general, there were 828 surgical site infections out of 11,611 patients in a single dose group (7.13%) and 762 surgical site infections out of 11,188 patients in multiple doses group (6.81%) (OR = 1.05, lower CI = 0.93, upper CI = 1.20). The difference between groups was not significant. Conclusion The present study showed that using a single-dose antimicrobial prophylaxis was equally effective as using multiple doses of antibiotics in decreasing surgical site infections.
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Affiliation(s)
- Nehad J. Ahmed
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Alkharj, Saudi Arabia
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Pulau Pinang, Malaysia
| | - Abdul Haseeb
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Abdullmoin AlQarni
- Infectious Diseases Department, Alnoor Specialist Hospital, Makkah, Saudi Arabia
| | - Manal AlGethamy
- Department of Infection Prevention & Control Program, Alnoor Specialist Hospital Makkah, Makkah, Saudi Arabia
| | - Ahmad J. Mahrous
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Ahmed M. Alshehri
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Alkharj, Saudi Arabia
| | - Abdullah K Alahmari
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Alkharj, Saudi Arabia
| | | | | | - Amer H. Khan
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Pulau Pinang, Malaysia
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Sheikh S, Swapnil K, Tripathi CD, Meshram GG, Karim BA. Intra-operative drug level monitoring of pre-operative antibiotic for surgical prophylaxis in the patients of elective spinal surgery. J Basic Clin Physiol Pharmacol 2023; 34:797-804. [PMID: 37690813 DOI: 10.1515/jbcpp-2023-0104] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 08/21/2023] [Indexed: 09/12/2023]
Abstract
OBJECTIVES Single dose prophylaxis is good enough for general surgery with low risk patients. However, the evidence for the effectiveness of single dose anti-microbial prophylaxis (AMP) is not conclusive in high risk patients and spinal surgeries requiring instrumentation or the use of implants in particular. No studies have explored the various concentration of ceftriaxone in plasma and tissue as well during an ongoing spinal surgery. Therefore, the objective of study was to correlate the serum and tissue concentrations of ceftriaxone with the SSI and identify patients with increased risk of SSI. METHODS It was an open label prospective study in 50 consecutive patients who underwent elective spine surgery under prophylactic cover of ceftriaxone. Serum and tissue concentration were estimated by high pressure liquid chromatography during the ongoing surgery. RESULTS Subjects were observed for any post-operative complications including SSI. Serum (p=0.002) and tissue (p=0.012) concentrations of ceftriaxone at the closure of spinal surgery were associated with SSI. Duration of the surgery (p=0.04) and use of implants (p=0.02) were also important surgery related risk factors. CONCLUSIONS Serum and tissue concentrations of ceftriaxone at the closure and duration of surgery and instrumentation or use of implants in the spinal surgery are good predictors of SSI.
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Affiliation(s)
- Salim Sheikh
- Department of Pharmacology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
- Department of Pharmacology, Dr. Baba Saheb Ambedkar Medical College and Hospital, New Delhi, India
| | - Kumar Swapnil
- Department of Pharmacology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
- Department of Orthopaedics, Government Medical College, Chandigarh, India
| | - Chakra Dhar Tripathi
- Department of Pharmacology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Girish Gulab Meshram
- Department of Pharmacology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
- Department of Pharmacology, Maulana Azad Medical College and Associated Hospitals, New Delhi, India
| | - Bushra Ahmed Karim
- Department of Public Health Dentistry, Jamia Millia Islamia, New Delhi, India
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MENENDEZ GARCIA M, OTERMIN MAYA I, LIBRERO LOPEZ J, GUTIERREZ DUBOIS J, MANRIQUE CUEVAS D, ALAEZ CRUZ JI, AZCONA SALVATIERRA L, AYECHU DIAZ I, HIDALGO OVEJERO AM. Effects of extended oral antibiotic prophylaxis on surgical site infections after instrumented spinal fusion: a cohort study of 901 patients with a minimum follow-up of 1 year. Acta Orthop 2023; 94:80-86. [PMID: 36802177 PMCID: PMC9942604 DOI: 10.2340/17453674.2023.9409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND AND PURPOSE We aimed to determine whether an extended oral antibiotic prophylaxis protocol may reduce the rate of surgical site infection (SSI) in patients undergoing instrumented spinal fusion. PATIENTS AND METHODS This retrospective cohort study comprise 901 consecutive patients subjected to spinal fusion between September 2011 and December 2018 with a minimum 1-year follow-up. 368 patients operated on between September 2011 and August 2014 were administered standard intravenous prophylaxis. 533 patients operated on between September 2014 and December 2018 were administered an extended protocol with 500 mg of oral cefuroxime axetil every 12 hours (clindamycin or levofloxacin in allergic individuals) until the removal of sutures. SSI was defined following the Centers for Disease Control and Prevention criteria. The association between risk factors and the incidence of SSI was evaluated by odds ratio (OR) with a multiple logistic regression model. RESULTS The bivariate analysis showed a statistically significant association between SSI and the type of prophylaxis used ("extended"' = 1.7% vs. "standard" = 6.2%, p= 0.001), with a lower proportion of superficial SSIs with the extended regimen (0.8% vs. 4.1%, p = 0.001). The multiple logistic regression model showed an OR = 0.25 (95% confidence interval [CI] 0.10-0.53) for extended prophylaxis and an OR = 3.5 (CI 1.3-8.1) for non-beta-lactams antibiotics. CONCLUSION Extended antibiotic prophylaxis seems to be associated with a reduction in the incidence of superficial SSI in instrumented spine surgery.
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Affiliation(s)
- Miguel MENENDEZ GARCIA
- Spine Surgery Unit, Department of Trauma and Orthopaedics, Hospital Universitario de Navarra, Pamplona (Navarra)
| | - Iñaki OTERMIN MAYA
- Internal Medicine Department, Hospital Universitario de Navarra, Pamplona (Navarra)
| | | | | | - Diego MANRIQUE CUEVAS
- Spine Surgery Unit, Department of Trauma and Orthopaedics, Hospital Universitario de Navarra, Pamplona (Navarra)
| | | | - Leyre AZCONA SALVATIERRA
- Spine Surgery Unit, Department of Trauma and Orthopaedics, Hospital Universitario de Navarra, Pamplona (Navarra)
| | - Isabel AYECHU DIAZ
- Spine Surgery Unit, Department of Trauma and Orthopaedics, Hospital Universitario de Navarra, Pamplona (Navarra)
| | - Angel M HIDALGO OVEJERO
- Spine Surgery Unit, Department of Trauma and Orthopaedics, Hospital Universitario de Navarra, Pamplona (Navarra)
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Porter MW, Burdi W, Casavant JD, Eastment MC, Tulloch-Palomino LG. Association between duration of antimicrobial prophylaxis and postoperative outcomes after lumbar spine surgery. Infect Control Hosp Epidemiol 2022; 43:1873-1879. [PMID: 35166198 PMCID: PMC9753085 DOI: 10.1017/ice.2021.529] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 12/01/2021] [Accepted: 12/17/2021] [Indexed: 01/14/2023]
Abstract
OBJECTIVES To describe the association between duration of antimicrobial prophylaxis (AMP) and 30-day surgical site infection (SSI), 7-day acute kidney injury (AKI), 90-day Clostridioides difficile infection (CDI), prolonged hospitalization, and 30-day reoperation after lumbar spine surgery for noninfectious indications, and to report adherence to current guidelines. DESIGN Survey. PARTICIPANTS AND SETTING The study cohort comprised 6,198 patients who underwent lumbar spine surgery for noninfectious indications across 137 Veterans' Health Administration surgery centers between 2016 and 2020. METHODS Used univariate and multivariate logistic regression to determine the association between type and duration of AMP with 30-day SSI, 7-day AKI, 90-day CDI, prolonged hospitalization, and 30-day reoperation. RESULTS Only 1,160 participants (18.7%) received the recommended duration of AMP. On multivariate analysis, the use of multiple prophylactic antimicrobials was associated with increased odds of 90-day CDI (adjusted odds ratio [aOR], 5.5; 95% confidence interval [CI], 1.1-28.2) and 30-day reoperation (aOR, 2.3; 95% CI, 1.2-4.4). Courses of antimicrobials ≥3 days were associated with increased odds of prolonged hospitalization (aOR,1.8; 95% CI, 1.4-2.3) and 30-day reoperation (aOR, 3.5; 95% CI, 2.2-5.7). In univariate analysis, increasing days of AMP was associated with a trend toward increasing odds of 90-day CDI (cOR, 1.4; 95% CI, 1.0-1.8 per additional day; P = .056). CONCLUSIONS Longer courses of AMP after lumbar spine surgery were associated with higher odds of CDI, prolonged hospitalization, and reoperation, but not with lower odds of SSI. However, adherence to the recommended duration of AMP is very low, hinting at a wide evidence-to-practice gap that needs to be addressed by spine surgeons and antimicrobial stewardship programs.
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Affiliation(s)
- Mary W. Porter
- Pharmacy Services, VA Puget Sound Health Care System, Seattle, Washington
| | - William Burdi
- Pharmacy Services, VA Puget Sound Health Care System, Seattle, Washington
| | | | - McKenna C. Eastment
- Hospital and Specialty Medicine, VA Puget Sound Health Care System, Seattle, Washington
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Luis G. Tulloch-Palomino
- Hospital and Specialty Medicine, VA Puget Sound Health Care System, Seattle, Washington
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
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Marino AC, Robinson ED, Durden JA, Cox HL, Mathers AJ, Shaffrey ME. The effects of avoiding extended antimicrobial drain prophylaxis on Clostridioides difficile and postprocedural infection rates: a 5-year retrospective. J Neurosurg 2022; 137:1153-1159. [PMID: 35171828 DOI: 10.3171/2021.11.jns211459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 11/15/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Postprocedural infection is a consequential complication of neurosurgical intervention. Periprocedural antimicrobial prophylaxis is routinely administered to prevent infection, and in some cases, continued for extended periods while surgical drains remain in place. However, there is little evidence that extended antimicrobial administration is necessary to reduce postprocedural infection, and extended antimicrobials can be associated with harm, such as Clostridioides difficile infection. The authors sought to evaluate whether shortening the duration of postprocedural antimicrobial prophylaxis would decrease the incidence of C. difficile infection without increasing the incidence of postprocedural infection. METHODS In this retrospective study, two general neurosurgical cohorts were examined. In one cohort, postoperative antimicrobial prophylaxis was limited to 24 hours; in the other, some patients received extended postoperative antimicrobial prophylaxis while surgical drains or external ventricular drains (EVDs) remained in place. Rates of infection with C. difficile as well as postprocedural infection after surgery and EVD placement were compared. RESULTS Seven thousand two hundred four patients undergoing 8586 surgical procedures and 413 EVD placements were reviewed. The incidence of C. difficile infection decreased significantly from 0.5% per procedural encounter to 0.07% with the discontinuation of extended postprocedural antibiotics within 90 days of a procedure. Rates of postprocedural infection and EVD infection did not significantly change. Results were similar in subgroups of patients with closed suction drains as well as cranial and spine subgroups. CONCLUSIONS Discontinuation of extended antimicrobial prophylaxis was associated with a significant decrease in the incidence of C. difficile infection without a concomitant change in postprocedural infections or EVD-associated infection. This study provides evidence in support of specialtfy-wide discontinuation of extended postoperative antimicrobial prophylaxis, even in the presence of closed suction drains.
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Affiliation(s)
| | - Evan D Robinson
- 2Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia
| | | | - Heather L Cox
- 2Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia
- 4Department of Pharmacy Services, University of Virginia Health, Charlottesville, Virginia
| | - Amy J Mathers
- 2Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia
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Cefazolin prophylaxis in spine surgery: patients are frequently underdosed and at increased risk for infection. Spine J 2022; 22:1442-1450. [PMID: 35680016 DOI: 10.1016/j.spinee.2022.05.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/03/2022] [Accepted: 05/25/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Perioperative antibiotics are critical in reducing the risk of postoperative spine infections. However, the efficacy and optimal weight-based prophylactic cefazolin dosing is unclear. PURPOSE To determine (1) if inadequate weight-based prophylactic dosing of cefazolin affects infection rates after spinal fusions, and (2) identify the optimal dosing of cefazolin. STUDY DESIGN/SETTING Single center retrospective cohort PATIENT SAMPLE: Patients undergoing posterior cervical or lumbar spinal fusion between January 2000 and October 2020 OUTCOME MEASURES: Postoperative surgical site infection status METHODS: Patients were grouped based on our institutionally derived dosing adequacy standards, 1 g for <60 kg, 2 g for 60 to 120 kg, and 3 g for >120 kg. Univariate comparisons and multivariate regressions identified the effect of inadequate dosing on infection rate. Patients were subsequently regrouped into cefazolin dose (grams) administered and logistic regression and receiver operating characteristic curves were compiled to determine the probability of infection based on cefazolin dose and patient weight. Alpha was set at 0.05. RESULTS A total of 2,643 patients met inclusion criteria and 95 infections (3.6%) were identified. The infection rate was higher in the inadequate dosing group (5.86% vs. 2.58%, p<.001). Adequate dosing was a predictor of decreased infections after lumbar fusion (OR: 0.43, p<.001), but not posterior cervical fusions (OR: 0.47, p=.065). Patients were subsequently regrouped into 1 g or 2 g of cefazolin administered resulting in a 5.01% and 2.77% infection rate, respectively (p=.005). The area under the curve (AUC) and 95% confidence interval for one (0.850 [0.777-0.924]) and two (0.575 [0.493-0.657]) g of cefazolin demonstrated lower infection rates for patients given 2 g cefazolin. CONCLUSIONS Patients receiving an inadequate weight-based dose of preoperative cefazolin had an increased risk of infection following spinal fusion surgery. Two grams prophylactic cefazolin significantly reduces the likelihood of infection.
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Is the routine use of systemic antibiotics after spine surgery warranted? A systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:2481-2492. [PMID: 35786772 DOI: 10.1007/s00586-022-07294-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/17/2022] [Accepted: 06/08/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE To determine whether the published literature supports the current practice of utilizing antibiotics postoperatively in spine surgery. METHODS A systematic review from PubMed and Cochrane Central Register of Controlled trials databases was performed. Search terms used: "Antibiotic Prophylaxis"[Mesh], antibiotic*, antibacterial*, "Spine"[Mesh], "Surgical Procedures, Operative"[Mesh]. Only comparative, clinical studies were included. Those studies with surgical site infection (SSI) criteria that were not similar to the CDC definition were excluded. A meta-analysis for overall SSI was performed. A subgroup analysis was also performed to analyze the outcomes specifically on instrumented groups of patients. A random-effects model was used to calculate risk ratios (RR). Forest plots were used to display RR and 95% confidence intervals (CI). RESULTS Thirteen studies were included (four Randomized-Controlled Trials, three prospective cohorts, and six retrospective). Three different perioperative strategies were used in the selected studies: Group 1: preoperative antibiotic administration (PreopAbx) versus PreopAbx and any type of postoperative antibiotic administration (Pre + postopAbx) (n = 6 studies; 7849 patients); Group 2: Pre + postopAbx ≤ 24 h versus Pre + postopAbx > 24 h (n = 6; 1982); and Group 3: Pre + postopAbx ≤ 48 h versus. Pre + postopAbx ≤ 72 h (n = 1; 502). The meta-analysis performed on Groups 1 and 2 did not show significant effects (RR = 1.27, 95% CI = 0.77, 2.09, and RR = 0.97, 95% CI = 0.64, 1.46, respectively). CONCLUSION A meta-analysis and comprehensive review of the literature show that the routine use of postoperative antibiotics in spine surgery may not be effective in preventing surgical site infections.
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Karczewski D, Schnake KJ, Osterhoff G, Spiegl U, Scheyerer MJ, Ullrich B, Pumberger M. Postoperative Spinal Implant Infections (PSII)-A Systematic Review: What Do We Know So Far and What is Critical About It? Global Spine J 2022; 12:1231-1246. [PMID: 34151619 PMCID: PMC9210225 DOI: 10.1177/21925682211024198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVES Postoperative spinal implant infections (PSII) are an increasing challenge in the daily clinical routine. This review summarizes existing knowledge in the field of PSII, including definitions, epidemiology, classifications, risk factors, pathogenesis, symptoms, diagnosis, and treatment. METHODS A systematic review was performed using a structured PubMed analysis, based on the PRISMA criteria. The search terminology was set as: "spinal implant associated infection OR spinal implant infection OR spinal instrumentation infection OR peri spinal implant infection." PubMed search was limited to the categories randomized controlled trials (RCT), clinical trials, meta-analysis and (systematic) reviews, whereas case reports were excluded. Studies from January 2000 to December 2020 were considered eligible. A total of 572 studies were identified, 82 references included for qualitative synthesis, and 19 for detailed sub analysis (12 meta-analysis, 7 prospective RCT). RESULTS Structural problems in the field of PSII were revealed, including (1) limited level of evidence in clinical studies (missing prospective RCT, metanalyzes), (2) small patient numbers, (3) missing standardized definitions, (4) heterogeneity in patient groups, and (5) redundancy in cited literature. CONCLUSION Evidence-based knowledge about spinal implant-associated infections is lacking. All involved medical fields should come together to define the term PSII and to combine their approaches toward research, training, and patient care.
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Affiliation(s)
- Daniel Karczewski
- Center for Musculoskeletal Surgery, Department of Orthopaedic Surgery, Charité–Universitaetsmedizin Berlin, Berlin, Germany,Daniel Karczewski, Department of Orthopaedics, Center for Musculoskeletal Surgery, Charité—Universitätsmedizin Berlin, Charitéplatz 1, D-10117 Berlin, Germany.
| | - Klaus J. Schnake
- Center for Spinal and Scoliosis Surgery, Malteser Waldkrankenhaus St. Marien, Erlangen, Germany,Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, Nuremberg, Germany
| | - Georg Osterhoff
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Ulrich Spiegl
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Max J. Scheyerer
- Department of Orthopedic and Trauma Surgery, Medical Faculty, University of Cologne, Cologne, Germany
| | - Bernhard Ullrich
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany,Department of Trauma and Reconstructive Surgery, BG Clinic Bergmannstrost, Halle (Saale), Germany
| | - Matthias Pumberger
- Center for Musculoskeletal Surgery, Department of Orthopaedic Surgery, Charité–Universitaetsmedizin Berlin, Berlin, Germany
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Surgical Antimicrobial Prophylaxis in Neonates and Children Undergoing Neurosurgery: A RAND/UCLA Appropriateness Method Consensus Study. Antibiotics (Basel) 2022; 11:antibiotics11070856. [PMID: 35884111 PMCID: PMC9311924 DOI: 10.3390/antibiotics11070856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/17/2022] [Accepted: 06/22/2022] [Indexed: 11/25/2022] Open
Abstract
Pediatric neurosurgery is a highly specialized branch of surgery in which surgical site infections (SSIs) are potentially serious complications that can also adversely affect a good surgical outcome, compromising functional recovery and, in some cases, even putting the patient’s life at risk. The main aim of this consensus document is to provide clinicians with a series of recommendations on antimicrobial prophylaxis for neonates and children undergoing neurosurgery. The following scenarios were considered: (1) craniotomy or cranial/cranio-facial approach to craniosynostosis; (2) neurosurgery with a trans-nasal-trans-sphenoidal approach; (3) non-penetrating head injuries; (4) penetrating head fracture; (5) spinal surgery (extradural and intradural); (6) shunt surgery or neuroendoscopy; (7) neuroendovascular procedures. Patients undergoing neurosurgery often undergo peri-operative antibiotic prophylaxis, with different schedules, not always supported by scientific evidence. This consensus provides clear and shared indications, based on the most updated literature. This work has been made possible by the multidisciplinary contribution of experts belonging to the most important Italian scientific societies, and represents, in our opinion, the most complete and up-to-date collection of recommendations on the behavior to be held in the peri-operative setting in this type of intervention, in order to guide physicians in the management of the patient, standardize approaches and avoid abuse and misuse of antibiotics.
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14
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Shi K, Chen X, Shen B, Luo Y, Lin R, Huang Y. The use of novel knotless barbed sutures in posterior long-segment lumbar surgery: a randomized controlled trial. J Orthop Surg Res 2022; 17:279. [PMID: 35585558 PMCID: PMC9118583 DOI: 10.1186/s13018-022-03165-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 05/05/2022] [Indexed: 11/16/2022] Open
Abstract
Background The study carries the aim to compare the clinical efficacy and economic outcomes of using barbed suture closure versus conventional closure for wounds after posterior long-segment lumbar surgery. Methods One hundred and eighty-one patients undertaking posterior long-segment lumbar surgery participated in the prospective randomized controlled trial study to receive either barbed suture wound closure (n = 91) or conventional suture closure (n = 90). Outcome measures included operating room time (ORT), wound closure time, length of incision, length of hospital stay (LOS), 90-day readmission rates, wound complications of dehiscence and infection, and costs. Results Barbed suture group was related with significantly lower ORT (P = 0.036), wound closure time (P < 0.001) and average wound closure time (P < 0.001), and significantly lower wound complication rates (dehiscence and infection) (P = 0.031). No significant differences were found when compared with conventional suture group in terms of length of incision (P = 0.086), length of hospital stay (P = 0.174), readmission rates up to 90 days after the surgical procedure (P = 0.232) and costs (P = 0.205). Conclusion The study suggested the knotless barbed suture technique outperformed the conventional suture in shortening operating room time, wound closure time and average wound closure time, and reducing wound complication rates.
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Affiliation(s)
- Kai Shi
- Department of Spinal Surgery, The First Affiliated Hospital of Fujian Medical University, No. 20 Chazhong Rd., Taijiang District, Fuzhou, 350005, Fujian Province, China
| | - Xuanwei Chen
- Department of Spinal Surgery, The First Affiliated Hospital of Fujian Medical University, No. 20 Chazhong Rd., Taijiang District, Fuzhou, 350005, Fujian Province, China
| | - Bin Shen
- School of Foreign Languages, Fuzhou University, No. 2 Xueyuan Rd, University Town, Fuzhou, 350004, Fujian Province, China
| | - Yue Luo
- Fujian Medical University, No. 88 Jiaotong Rd., Taijiang District, Fuzhou, 350005, Fujian Province, China
| | - Renqin Lin
- Department of Spinal Surgery, The First Affiliated Hospital of Fujian Medical University, No. 20 Chazhong Rd., Taijiang District, Fuzhou, 350005, Fujian Province, China
| | - Yu Huang
- Department of Spinal Surgery, The First Affiliated Hospital of Fujian Medical University, No. 20 Chazhong Rd., Taijiang District, Fuzhou, 350005, Fujian Province, China.
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15
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Nagata K, Yamada K, Shinozaki T, Miyazaki T, Tokimura F, Tajiri Y, Matsumoto T, Yamakawa K, Oka H, Higashikawa A, Sato T, Kawano K, Karita T, Koyama T, Hozumi T, Abe H, Hodohara M, Kohata K, Toyonaga M, Oshima Y, Tanaka S, Okazaki H. Effect of Antimicrobial Prophylaxis Duration on Health Care-Associated Infections After Clean Orthopedic Surgery: A Cluster Randomized Trial. JAMA Netw Open 2022; 5:e226095. [PMID: 35412627 PMCID: PMC9006110 DOI: 10.1001/jamanetworkopen.2022.6095] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE Postoperative health care-associated infections are associated with a greater deterioration in patients' general health status and social and economic burden, with at least 1 occurring in approximately 4% of acute care hospital patients. Antimicrobial prophylaxis prevents surgical site infections in various orthopedic procedures; however, its relationship with health care-associated infections remains unknown. OBJECTIVE To examine whether a shorter antimicrobial prophylaxis duration of less than 24 hours after surgery is not inferior to a longer duration in preventing health care-associated infections after clean orthopedic surgery. DESIGN, SETTING, AND PARTICIPANTS This open-label, multicenter, cluster randomized, noninferiority clinical trial was conducted in 5 tertiary referral hospitals in greater Tokyo metropolitan area, Japan, from May to December 2018. Adult patients undergoing clean orthopedic surgery were recruited until the planned number of participants was achieved (500 participants per group). Statistical analysis was conducted from July to December 2019. INTERVENTIONS Antimicrobial prophylaxis was discontinued within 24 hours after surgery in group 24 and 24 to 48 hours after surgery in group 48. Group allocation was switched every 2 or 4 months according to the facility-based cluster rule. Study-group assignments were masked from participants. MAIN OUTCOMES AND MEASURES The primary outcome was the incidence of health care-associated infections requiring antibiotic therapies within 30 days after surgery. The noninferiority margin was 4%. RESULTS Of the 1211 participants who underwent cluster allocation, 633 participants were in group 24 (median [IQR] age, 73 [61-80] years; 250 men [39.5%] and 383 women [60.5%]), 578 participants were in group 48 (median [IQR] age, 74 [62-81] years; 204 men [35.3%] and 374 women [64.7%]), and all were eligible for the intention-to-treat analyses. Health care-associated infections occurred in 29 patients (4.6%) in group 24 and 38 patients (6.6%) in group 48. Intention-to-treat analyses showed a risk difference of -1.99 percentage points (95% CI, -5.05 to 1.06 percentage points; P < .001 for noninferiority) between groups, indicating noninferiority. Results of adjusted intention-to-treat, per-protocol, and per designated procedure population analyses supported this result, without a risk of antibiotic resistance and prolonged hospitalization. CONCLUSIONS AND RELEVANCE This cluster randomized trial found noninferiority of a shorter antimicrobial prophylaxis duration in preventing health care-associated infections without an increase in antibiotic resistance risk. These findings lend support to the global movement against antimicrobial resistance and provide additional information on adequate antimicrobial prophylaxis for clean orthopedic surgery. TRIAL REGISTRATION Identifier: UMIN000030929.
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Affiliation(s)
- Kosei Nagata
- Department of Orthopedic Surgery and Spinal Surgery, the University of Tokyo Hospital, Tokyo, Japan
| | - Koji Yamada
- Department of Orthopedic Surgery, Japan Organization of Occupational Health and Safety Kanto Rosai Hospital, Kanagawa, Japan
| | - Tomohiro Shinozaki
- Department of Information and Computer Technology, Faculty of Engineering, Tokyo University of Science, Tokyo, Japan
| | - Tsuyoshi Miyazaki
- Department of Orthopedic Surgery, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, Tokyo, Japan
| | - Fumiaki Tokimura
- Department of Orthopedic Surgery, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, Tokyo, Japan
| | - Yasuhito Tajiri
- Department of Orthopedic Surgery, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Takuya Matsumoto
- Department of Orthopedic Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Kiyofumi Yamakawa
- Department of Orthopedic Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Hiroyuki Oka
- Department of Medical Research and Management for Musculoskeletal Pain, 22nd Century Medical and Research Center, Faculty of Medicine, The University of Tokyo, Tokyo, Bunkyo-ku, Japan
| | - Akiro Higashikawa
- Department of Orthopedic Surgery, Japan Organization of Occupational Health and Safety Kanto Rosai Hospital, Kanagawa, Japan
| | - Toshihide Sato
- Department of Orthopedic Surgery, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Kenichi Kawano
- Department of Orthopedic Surgery, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Tatsuro Karita
- Department of Orthopedic Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Takuya Koyama
- Department of Orthopedic Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Takahiro Hozumi
- Department of Orthopedic Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Hiroaki Abe
- Department of Orthopedic Surgery, Japan Organization of Occupational Health and Safety Kanto Rosai Hospital, Kanagawa, Japan
| | - Makoto Hodohara
- Department of Orthopedic Surgery, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Kazuhiro Kohata
- Department of Orthopedic Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Masato Toyonaga
- Department of Orthopedic Surgery, Japan Organization of Occupational Health and Safety Kanto Rosai Hospital, Kanagawa, Japan
| | - Yasushi Oshima
- Department of Orthopedic Surgery and Spinal Surgery, the University of Tokyo Hospital, Tokyo, Japan
| | - Sakae Tanaka
- Department of Orthopedic Surgery and Spinal Surgery, the University of Tokyo Hospital, Tokyo, Japan
| | - Hiroshi Okazaki
- Department of Orthopedic Surgery, Japan Organization of Occupational Health and Safety Kanto Rosai Hospital, Kanagawa, Japan
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16
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Olsen MA, Greenberg JK, Peacock K, Nickel KB, Fraser VJ, Warren DK. Lack of association of post-discharge prophylactic antibiotics with decreased risk of surgical site infection following spinal fusion. J Antimicrob Chemother 2022; 77:1178-1184. [PMID: 35040936 PMCID: PMC9126069 DOI: 10.1093/jac/dkab475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/24/2021] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVES To determine the prevalence and factors associated with post-discharge prophylactic antibiotic use after spinal fusion and whether use was associated with decreased risk of surgical site infection (SSI). METHODS Persons aged 10-64 years undergoing spinal fusion between 1 January 2010 and 30 June 2015 were identified in the MarketScan Commercial Database. Complicated patients and those coded for infection from 30 days before to 2 days after the surgical admission were excluded. Outpatient oral antibiotics were identified within 2 days of surgical discharge. SSI was defined using ICD-9-CM diagnosis codes within 90 days of surgery. Generalized linear models were used to determine factors associated with post-discharge prophylactic antibiotic use and with SSI. RESULTS The cohort included 156 446 fusion procedures, with post-discharge prophylactic antibiotics used in 9223 (5.9%) surgeries. SSIs occurred after 2557 (1.6%) procedures. Factors significantly associated with post-discharge prophylactic antibiotics included history of lymphoma, diabetes, 3-7 versus 1-2 vertebral levels fused, and non-infectious postoperative complications. In multivariable analysis, post-discharge prophylactic antibiotic use was not associated with SSI risk after spinal fusion (relative risk 0.98; 95% CI 0.84-1.14). CONCLUSIONS Post-discharge prophylactic oral antibiotics after spinal fusion were used more commonly in patients with major medical comorbidities, more complex surgeries and those with postoperative complications during the surgical admission. After adjusting for surgical complexity and infection risk factors, post-discharge prophylactic antibiotic use was not associated with decreased SSI risk. These results suggest that prolonged prophylactic antibiotic use should be avoided after spine surgery, given the lack of benefit and potential for harm.
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Affiliation(s)
- Margaret A. Olsen
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
- Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - Jacob K. Greenberg
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Kate Peacock
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - Katelin B. Nickel
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - Victoria J. Fraser
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - David K. Warren
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
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Macki M, Hamilton T, Lim S, Mansour TR, Telemi E, Bazydlo M, Schultz L, Nerenz DR, Park P, Chang V, Schwalb J, Abdulhak MM. The role of postoperative antibiotic duration on surgical site infection after lumbar surgery. J Neurosurg Spine 2022; 36:254-260. [PMID: 34534952 DOI: 10.3171/2021.4.spine201839] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 04/01/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Despite a general consensus regarding the administration of preoperative antibiotics, poorly defined comparison groups and underpowered studies prevent clear guidelines for postoperative antibiotics. Utilizing a data set tailored specifically to spine surgery outcomes, in this clinical study the authors aimed to determine whether there is a role for postoperative antibiotics in the prevention of surgical site infection (SSI). METHODS The Michigan Spine Surgery Improvement Collaborative registry was queried for all lumbar operations performed for degenerative spinal pathologies over a 5-year period from 2014 to 2019. Preoperative prophylactic antibiotics were administered for all surgical procedures. The study population was divided into three cohorts: no postoperative antibiotics, postoperative antibiotics ≤ 24 hours, and postoperative antibiotics > 24 hours. This categorization was intended to determine 1) whether postoperative antibiotics are helpful and 2) the appropriate duration of postoperative antibiotics. First, multivariable analysis with generalized estimating equations (GEEs) was used to determine the association between antibiotic duration and all-type SSI with adjusted odds ratios; second, a three-tiered outcome-no SSI, superficial SSI, and deep SSI-was calculated with multivariable multinomial logistical GEE analysis. RESULTS Among 37,161 patients, the postoperative antibiotics > 24 hours cohort had more men with older average age, greater body mass index, and greater comorbidity burden. The postoperative antibiotics > 24 hours cohort had a 3% rate of SSI, which was significantly higher than the 2% rate of SSI of the other two cohorts (p = 0.004). On multivariable GEE analysis, neither postoperative antibiotics > 24 hours nor postoperative antibiotics ≤ 24 hours, as compared with no postoperative antibiotics, was associated with a lower rate of all-type postoperative SSIs. On multivariable multinomial logistical GEE analysis, neither postoperative antibiotics ≤ 24 hours nor postoperative antibiotics > 24 hours was associated with rate of superficial SSI, as compared with no antibiotic use at all. The odds of deep SSI decreased by 45% with postoperative antibiotics ≤ 24 hours (p = 0.002) and by 40% with postoperative antibiotics > 24 hours (p = 0.008). CONCLUSIONS Although the incidence of all-type SSI was highest in the antibiotics > 24 hours cohort, which also had the highest proportions of risk factors, duration of antibiotics failed to predict all-type SSI. On multinomial subanalysis, administration of postoperative antibiotics for both ≤ 24 hours and > 24 hours was associated with decreased risk of only deep SSI but not superficial SSI. Spine surgeons can safely consider antibiotics for 24 hours, which is equally as effective as long-term administration for prophylaxis against deep SSI.
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Affiliation(s)
| | | | | | | | | | | | | | - David R Nerenz
- 3Center for Health Policy and Health Services Research, Henry Ford Hospital, Detroit, Michigan; and
| | - Paul Park
- 4University of Michigan, Ann Arbor, Michigan
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Shuman WH, Baron RB, Gal JS, Li AY, Neifert SN, Hannah TC, Dreher N, Schupper AJ, Steinberger JM, Caridi JM, Choudhri TF. Seasonal Effects on Surgical Site Infections Following Spine Surgery. World Neurosurg 2022; 161:e174-e182. [DOI: 10.1016/j.wneu.2022.01.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 01/23/2022] [Accepted: 01/23/2022] [Indexed: 11/28/2022]
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Mohammadi E, Azadnajafabad S, Goudarzi M, Tayebi Meybodi K, Nejat F, Habibi Z. Single-dose antibiotic prophylaxis compared with multiple-dose protocol in clean pediatric neurosurgical interventions: a nonrandomized, historically controlled equivalence trial. J Neurosurg Pediatr 2021:1-8. [PMID: 34861647 DOI: 10.3171/2021.9.peds21416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 09/16/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Guidelines recommend antimicrobial prophylaxis (AMP) preoperatively for "clean" spinal and cranial surgeries, while dose and timing remain controversial. The use of multiple-dose AMP for such surgeries is under debate in the pediatric context. In this clinical study, the authors aimed to compare single-dose with multiple-dose prophylactic antibiotic usage in cranial and spinal neurosurgical interventions of pediatric patients. METHODS All neurosurgical patients aged 28 days to 18 years who underwent surgery at a single tertiary center were assessed. Three cohorts (noninstrumented clean spinal, noninstrumented cranial, and instrumented cranial interventions), each of which comprised two 50-patient arms (i.e., single-dose AMP and multiple-dose AMP), were included after propensity score-matched retrospective sampling and power analysis. Records were examined for surgical site infections. Using a previously published meta-analysis as the prior and 80% acceptance of equivalence (margin of OR 0.88-1.13), logistic regression was carried out for the total cohort and each subcohort and adjusted for etiology by consideration of multiple-dose AMP as reference. RESULTS The overall sample included 300 age- and sex-matched patients who were evenly distributed in 3 bi-arm cohorts. There was no statistical intercohort difference based on etiology or type of operation (p < 0.05). Equivalence analysis revealed nondiscriminating results for the total cohort (adjusted OR 0.65, 95% CI 0.27-1.57) and each of the subcohorts (noninstrumented clean spinal, adjusted OR 0.65, 95% CI 0.12-3.44; noninstrumented cranial, adjusted OR 0.52, 95% CI 0.14-2.73; and instrumented cranial, adjusted OR 0.68, 95% CI 0.13-3.31). CONCLUSIONS No significant benefit for multiple-dose compared with single-dose AMPs in any of the pediatric neurosurgery settings could be detected. Since unnecessary antibiotic use should be avoided as much as possible, it seems that usage of single-dose AMP is indicated.
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Affiliation(s)
- Esmaeil Mohammadi
- 1Department of Pediatric Neurosurgery, Children's Medical Center Hospital, Tehran University of Medical Sciences, Tehran
| | - Sina Azadnajafabad
- 1Department of Pediatric Neurosurgery, Children's Medical Center Hospital, Tehran University of Medical Sciences, Tehran.,2Department of Surgery, Tehran University of Medical Sciences, Tehran; and
| | - Mehrdad Goudarzi
- 3Department of Pediatric Anesthesiology, Children's Medical Center Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Keyvan Tayebi Meybodi
- 1Department of Pediatric Neurosurgery, Children's Medical Center Hospital, Tehran University of Medical Sciences, Tehran
| | - Farideh Nejat
- 1Department of Pediatric Neurosurgery, Children's Medical Center Hospital, Tehran University of Medical Sciences, Tehran
| | - Zohreh Habibi
- 1Department of Pediatric Neurosurgery, Children's Medical Center Hospital, Tehran University of Medical Sciences, Tehran
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20
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Pivazyan G, Mualem W, D'Antuono MR, Dowlati E, Nair N, Mueller KB. The Utility of Prolonged Prophylactic Systemic Antibiotics (PPSA) for Subfascial Drains After Degenerative Spine Surgery. Spine (Phila Pa 1976) 2021; 46:E1077-E1082. [PMID: 33710111 DOI: 10.1097/brs.0000000000004031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The aim of the current investigation was to evaluate the impact of prolonged prophylactic systemic antibiotics (PPSA) on the development of surgical site infection rate (SSIR) in degenerative spine surgery. SUMMARY OF BACKGROUND DATA Surgical drains are utilized postoperatively in posterior spine surgery to help minimize the risk of seroma formation. Prophylactic antibiotics while drains are in place are frequently used to reduce SSIR, though the practice remains controversial. METHODS We performed a single center, retrospective review of all patients that underwent posterior spinal surgery for cervical and lumbar degenerative pathology over a 3.5 year period (January 2016-July 2019). Patients underwent a traditional open posterior midline procedure with postoperative placement of a subfascial surgical drain. Antibiotics were administered for the duration of the drain (PPSA group) or for 24 hours postoperatively (non-PPSA group). The number of surgical site infections, organism, and Clostridium difficile infections was recorded. RESULTS Three hundred thirty six patients were identified, 168 patients in the PPSA group and 168 in the non-PPSA groups. The overall SSIR was 5.36% (18/336). The SSIR for the non-PPSA and PPSA groups were 7.14% (12/168) and 3.57% (6/168), respectively (P = 0.146). While difference of SSIR between the groups was two-fold, it was not statistically significant. For the non-PPSA and PPSA groups, the SSIR for cervical (5.95% [5/84] vs. 2.38% [2/84], P = 0.443) and lumbar (8.33% [7/84], vs. 4.76% [4/84], P = 0.535) regions were not significantly different. C. difficile cases in the PPSA and non-PPSA groups were 1/168 and 0/168 respectively (P = 1.00). CONCLUSION Our series demonstrate a two-fold reduction of SSI with implementation of PPSA regimen. This benefit was demonstrated separately for both cervical and lumbar regions. Randomized trials and increase in sample size are warranted to elucidate the significance of PPSA in posterior spinal surgery.Level of Evidence: 3.
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Affiliation(s)
- Gnel Pivazyan
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, DC
| | - William Mualem
- Georgetown University School of Medicine, Washington, DC
| | | | - Ehsan Dowlati
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, DC
| | - Nathan Nair
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, DC
| | - Kyle B Mueller
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, DC
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Amelot A, Riche M, Latreille S, Degos V, Carpentier A, Mathon B, Korinek AM. Antimicrobial prophylaxis in noninstrumented spine surgery: a prospective study to determine efficacy and drawbacks. J Neurosurg Spine 2021; 35:366-375. [PMID: 34243156 DOI: 10.3171/2020.11.spine201891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 11/23/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors sought to evaluate the roles of perioperative antibiotic prophylaxis in noninstrumented spine surgery (NISS), both in postoperative infections and the impact on the selection of resistant bacteria. To the authors' knowledge, only one prospective study recommending preoperative intravenous (IV) antibiotics for prophylaxis has been published previously. METHODS Two successive prospective IV antibiotic prophylaxis protocols were used: from 2011 to 2013 (group A: no prophylactic antibiotic) and from 2014 to 2016 (group B: prophylactic cefazolin). Patient infection rates, infection risk factors, and bacteriological status were determined. RESULTS In total, 2250 patients (1031 in group A and 1219 in group B) were followed for at least 1 year. The authors identified 72 surgical site infections, 51 in group A (4.9%) and 21 in group B (1.7%) (p < 0.0001). A multiple logistic regression hazard model identified male sex (HR 2.028, 95% CI 1.173-3.509; p = 0.011), cervical laminectomy (HR 2.078, 95% CI 1.147-3.762; p = 0.016), and postoperative CSF leak (HR 43.782, 95% CI 10.9-189.9; p < 0.0001) as independent predictive risk factors of infection. In addition, preoperative antibiotic prophylaxis was the only independent favorable factor (HR 0.283, 95% CI 0.164-0.488; p < 0.0001) that significantly reduced infections for NISS. Of 97 bacterial infections, cefazolin-resistant bacteria were identified in 26 (26.8%), with significantly more in group B (40%) than in group A (20.9%) (p = 0.02). CONCLUSIONS A single dose of preoperative cefazolin is effective and mandatory in preventing surgical site infections in NISS. Single-dose antibiotic prophylaxis has an immediate impact on cutaneous flora by increasing cefazolin-resistant bacteria.
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Affiliation(s)
- Aymeric Amelot
- 1Department of Neurosurgery, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris
- 2Department of Neurosurgery, Bretonneau Hospital, Hopitaux de Tours
| | - Maximilien Riche
- 1Department of Neurosurgery, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris
| | - Samuel Latreille
- 3Department of Neuro-anesthesiology, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris; and
| | - Vincent Degos
- 3Department of Neuro-anesthesiology, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris; and
- 4Sorbonne University, Paris, France
| | - Alexandre Carpentier
- 1Department of Neurosurgery, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris
- 4Sorbonne University, Paris, France
| | - Bertrand Mathon
- 1Department of Neurosurgery, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris
- 4Sorbonne University, Paris, France
| | - Anne-Marie Korinek
- 3Department of Neuro-anesthesiology, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris; and
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White AJ, Fiani B, Jarrah R, Momin AA, Rasouli J. Surgical Site Infection Prophylaxis and Wound Management in Spine Surgery. Asian Spine J 2021; 16:451-461. [PMID: 34167274 PMCID: PMC9260408 DOI: 10.31616/asj.2020.0674] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 03/11/2021] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Alexandra J White
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Brian Fiani
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, CA, USA
| | - Ryan Jarrah
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Arbaz A Momin
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Jonathan Rasouli
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, USA
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Debono B, Wainwright TW, Wang MY, Sigmundsson FG, Yang MMH, Smid-Nanninga H, Bonnal A, Le Huec JC, Fawcett WJ, Ljungqvist O, Lonjon G, de Boer HD. Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Spine J 2021; 21:729-752. [PMID: 33444664 DOI: 10.1016/j.spinee.2021.01.001] [Citation(s) in RCA: 150] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 12/02/2020] [Accepted: 01/04/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) evidence-based protocols for perioperative care have led to improvements in outcomes in numerous surgical areas, through multimodal optimization of patient pathway, reduction of complications, improved patient experience and reduction in the length of stay. ERAS represent a relatively new paradigm in spine surgery. PURPOSE This multidisciplinary consensus review summarizes the literature and proposes recommendations for the perioperative care of patients undergoing lumbar fusion surgery with an ERAS program. STUDY DESIGN This is a review article. METHODS Under the impetus of the ERAS® society, a multidisciplinary guideline development group was constituted by bringing together international experts involved in the practice of ERAS and spine surgery. This group identified 22 ERAS items for lumbar fusion. A systematic search in the English language was performed in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. Systematic reviews, randomized controlled trials, and cohort studies were included, and the evidence was graded according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Consensus recommendation was reached by the group after a critical appraisal of the literature. RESULTS Two hundred fifty-six articles were included to develop the consensus statements for 22 ERAS items; one ERAS item (prehabilitation) was excluded from the final summary due to very poor quality and conflicting evidence in lumbar spinal fusion. From these remaining 21 ERAS items, 28 recommendations were included. All recommendations on ERAS protocol items are based on the best available evidence. These included nine preoperative, eleven intraoperative, and six postoperative recommendations. They span topics from preoperative patient education and nutritional evaluation, intraoperative anesthetic and surgical techniques, and postoperative multimodal analgesic strategies. The level of evidence for the use of each recommendation is presented. CONCLUSION Based on the best evidence available for each ERAS item within the multidisciplinary perioperative care pathways, the ERAS® Society presents this comprehensive consensus review for perioperative care in lumbar fusion.
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Affiliation(s)
- Bertrand Debono
- Paris-Versailles Spine Center (Centre Francilien du Dos), Paris, France; Ramsay Santé-Hôpital Privé de Versailles, Versailles, France.
| | - Thomas W Wainwright
- Research Institute, Bournemouth University, Bournemouth, UK; The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, Bournemouth, UK
| | - Michael Y Wang
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Freyr G Sigmundsson
- Department of Orthopedic Surgery, Örebro University Hospital, Södra Grev Rosengatan, Örebro, Sweden
| | - Michael M H Yang
- Department of Clinical Neurosciences, Section of Neurosurgery, University of Calgary, Calgary, Alberta, Canada
| | | | - Aurélien Bonnal
- Department of Anesthesiology, Clinique St-Jean- Sud de France, Santécité Group. St Jean de Vedas, Montpellier Metropole, France
| | - Jean-Charles Le Huec
- Department of Orthopedic Surgery - Polyclinique Bordeaux Nord Aquitaine, Bordeaux, France
| | - William J Fawcett
- Department of Anaesthesia, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Olle Ljungqvist
- School of Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden
| | - Guillaume Lonjon
- Department of Orthopedic Surgery, Orthosud, Clinique St-Jean- Sud de France, SantéCité Group. St Jean de Vedas, Montpellier Metropole, France
| | - Hans D de Boer
- Department of Anesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital Groningen, the Netherlands
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Al Farii H, Slawaska-Eng D, Pankovitch S, Navarro-Ramirez R, Weber M. Gram-Negative Surgical Site Infections After 989 Spinal Fusion Procedures: Associated Factors and the Role of Gram-Negative Prophylactic Antibiotic Coverage. Int J Spine Surg 2021; 15:341-347. [PMID: 33900992 DOI: 10.14444/8044] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND To identify, analyze, and report the patient- and procedure-related factors associated with surgical site infection (SSI) after spinal fusion (SF) surgery. METHODS We included any SSI-SF from January 2013 to September 2015. A total of 989 spine surgeries that required instrumentation were performed. RESULTS Twenty-four out of 989 (2.43%) patients presented with SSI. More than half of the SSI cases (54%) got infected with either exclusively gram-negative bacteria or a combination of gram-negative and gram-positive bacteria; 9.1% of the surgeries involved the sacral spine (90 out of 989 patients). SSI in long constructs (more than 3 levels) was performed in 66.7% compared with 33.3% with short constructs; 87.5 % of the reported SSI (21 patients) were done through a posterior approach. Of patients who had SSI, 87.5% received prophylactic antibiotics, 92% were operated on during the daytime shift, 50% required blood transfusion, and 79% required surgical debridement. Four patients out of 24 patients died (17%) due to unrelated SSI complications. CONCLUSIONS The overall incidence of gram-negative infections after long SFs remains low in our study population. Despite this low overall incidence, our results demonstrate a relative higher incidence of gram-negative SSIs in surgeries involving more than 3 spinal levels and for all those involving the sacral spine. We propose that there may be a potential benefit of gram-negative prophylactic antibiotic coverage in patients falling in either 1 of these categories. Further multivariate analysis and/or randomized studies may be necessary to confirm our results. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Humaid Al Farii
- Division of Orthopaedic Surgery, McGill University, Montreal, Quebec, Canada
| | - David Slawaska-Eng
- Division of Orthopaedic Surgery, McGill University, Montreal, Quebec, Canada
| | - Sarah Pankovitch
- Division of Orthopaedic Surgery, McGill University, Montreal, Quebec, Canada
| | | | - Michael Weber
- Division of Orthopaedic Surgery, McGill University, Montreal, Quebec, Canada
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Pei H, Wang H, Chen M, Ma L, Liu G, Ding W. Surgical site infection after posterior lumbar interbody fusion and instrumentation in patients with lumbar degenerative disease. Int Wound J 2021; 18:608-615. [PMID: 33580604 PMCID: PMC8450782 DOI: 10.1111/iwj.13562] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 01/16/2021] [Accepted: 01/21/2021] [Indexed: 12/02/2022] Open
Abstract
We designed this retrospective study with aims to investigate the incidence and risk factors associated with surgical site infection (SSI) following posterior lumbar interbody fusion (PLIF) and instrumentation in patients with lumbar degenerative disease. Eligible patients treated between January 2016 and June 2019 were included. Electronic medical records were inquired for data extraction and collection. Patients with SSI and without SSI were compared using the univariate analyses, and the association between variables and risk of SSI was investigated using multivariate logistics regression analyses. Among 1269 patients, 43 were found to have SSI, indicating a rate of 3.4%. Microbiological culture tests showed 88.4% patients had a positive result. Four SSIs were caused by mixed bacterial, and the remaining 34 by single bacteria. Multiple drug‐resistant strains were detected in 25 (65.8%) SSIs, with meticillin‐resistant coagulase‐negative staphylococcus (MRCNS) predominating (12, 48.0%). ASA III and above (odd ratio (OR), 1.67; 95% confidence interval (CI), 1.11 to 3.07), preoperative stay (OR, 1.13; 95% CI, 1.04 to 1.23), heart disease (OR, 2.88; 95% CI, 1.24 to 6.71), diabetes mellitus (OR, 3.28; 95% CI, 1.66 to 6.47) and renal insufficiency (OR, 4.23; 95% CI, 1.26 to 10.21), prolonged prophylactic antibiotics use (OR, 4.43; 95% CI, 2.30 to 8.54), and the reduced lymphocyte count (OR, 2.11; 95% CI, 1.03 to 4.33) were identified as independent risk factors associated with SSI. These factors, although most not modifiable, should be kept in mind, optimised for surgical conditions, or readily adjusted in the future postoperative management of antibiotics, to reduce postoperative SSIs.
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Affiliation(s)
- Honglei Pei
- Department of Orthopaedic Surgery, The 1st Hospital of Hebei Medical University, Shijiazhuang, Hebei, P. R. China
| | - Haiying Wang
- Department of Orthopaedic Surgery, The 1st Central Hospital of Baoding, Baoding, Hebei, P. R. China
| | - Meiyun Chen
- Department of General Medicine, the 2nd Hospital of Hebei Medical University, Shijiazhuang, Hebei, P. R. China
| | - Lei Ma
- Department of Spinal Surgery, The 3rd Hospital of Hebei Medical University, Shijiazhuang, Hebei, P. R. China
| | - Guobin Liu
- Department of Orthopaedic Surgery, The 1st Hospital of Hebei Medical University, Shijiazhuang, Hebei, P. R. China
| | - Wenyuan Ding
- Department of Spinal Surgery, The 3rd Hospital of Hebei Medical University, Shijiazhuang, Hebei, P. R. China
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Abola MV, Lin CC, Lin LJ, Schreiber-Stainthorp W, Frempong-Boadu A, Buckland AJ, Protopsaltis TS. Postoperative Prophylactic Antibiotics in Spine Surgery: A Propensity-Matched Analysis. J Bone Joint Surg Am 2021; 103:219-226. [PMID: 33315695 DOI: 10.2106/jbjs.20.00934] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Surgical site infections are common and costly complications after spine surgery. Prophylactic antibiotics are the standard of care; however, the appropriate duration of antibiotics has yet to be adequately addressed. We sought to determine whether the duration of antibiotic administration (preoperatively only versus preoperatively and for 24 hours postoperatively) impacts postoperative infection rates. METHODS All patients undergoing inpatient spinal procedures at a single institution from 2011 to 2018 were evaluated for inclusion. A minimum of 1 year of follow-up was used to adequately capture postoperative infections. The 1:1 nearest-neighbor propensity score matching technique was used between patients who did and did not receive postoperative antibiotics, and multivariable logistic regression analysis was conducted to control for confounding. RESULTS A total of 4,454 patients were evaluated and, of those, 2,672 (60%) received 24 hours of postoperative antibiotics and 1,782 (40%) received no postoperative antibiotics. After propensity-matched analysis, there was no difference between patients who received postoperative antibiotics and those who did not in terms of the infection rate (1.8% compared with 1.5%). No significant decrease in the odds of postoperative infection was noted in association with the use of postoperative antibiotics (odds ratio = 1.17; 95% confidence interval, 0.620 to 2.23; p = 0.628). Additionally, there was no observed increase in the risk of Clostridium difficile infection or in the short-term rate of infection with multidrug-resistant organisms. CONCLUSIONS There was no difference in the rate of surgical site infections between patients who received 24 hours of postoperative antibiotics and those who did not. Additionally, we found no observable risks, such as more antibiotic-resistant infections and C. difficile infections, with prolonged antibiotic use. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Matthew V Abola
- Department of Orthopedic Surgery, New York University Langone Orthopedic Hospital, NYU Langone Health, New York, NY
| | - Charles C Lin
- Department of Orthopedic Surgery, New York University Langone Orthopedic Hospital, NYU Langone Health, New York, NY
| | - Lawrence J Lin
- Department of Orthopedic Surgery, New York University Langone Orthopedic Hospital, NYU Langone Health, New York, NY
| | - William Schreiber-Stainthorp
- Department of Orthopedic Surgery, New York University Langone Orthopedic Hospital, NYU Langone Health, New York, NY
| | | | - Aaron J Buckland
- Department of Orthopedic Surgery, New York University Langone Orthopedic Hospital, NYU Langone Health, New York, NY
| | - Themistocles S Protopsaltis
- Department of Orthopedic Surgery, New York University Langone Orthopedic Hospital, NYU Langone Health, New York, NY
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Warren DK, Nickel KB, Han JH, Tolomeo P, Hostler CJ, Foy K, Banks IR, Fraser VJ, Olsen MA. Postdischarge antibiotic use for prophylaxis following spinal fusion. Infect Control Hosp Epidemiol 2020; 41:789-798. [PMID: 32366333 PMCID: PMC7641990 DOI: 10.1017/ice.2020.117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Despite recommendations to discontinue prophylactic antibiotics after incision closure or <24 hours after surgery, prophylactic antibiotics are continued after discharge by some clinicians. The objective of this study was to determine the prevalence and factors associated with postdischarge prophylactic antibiotic use after spinal fusion. DESIGN Multicenter retrospective cohort study. PATIENTS This study included patients aged ≥18 years undergoing spinal fusion or refusion between July 2011 and June 2015 at 3 sites. Patients with an infection during the surgical admission were excluded. METHODS Prophylactic antibiotics were identified at discharge. Factors associated with postdischarge prophylactic antibiotic use were identified using hierarchical generalized linear models. RESULTS In total, 8,652 spinal fusion admissions were included. Antibiotics were prescribed at discharge in 289 admissions (3.3%). The most commonly prescribed antibiotics were trimethoprim/sulfamethoxazole (22.1%), cephalexin (18.8%), and ciprofloxacin (17.1%). Adjusted for study site, significant factors associated with prophylactic discharge antibiotics included American Society of Anesthesiologists (ASA) class ≥3 (odds ratio [OR], 1.31; 95% CI, 1.00-1.70), lymphoma (OR, 2.57; 95% CI, 1.11-5.98), solid tumor (OR, 3.63; 95% CI, 1.62-8.14), morbid obesity (OR, 1.64; 95% CI, 1.09-2.47), paralysis (OR, 2.38; 95% CI, 1.30-4.37), hematoma/seroma (OR, 2.93; 95% CI, 1.17-7.33), thoracic surgery (OR, 1.39; 95% CI, 1.01-1.93), longer length of stay, and intraoperative antibiotics. CONCLUSIONS Postdischarge prophylactic antibiotics were uncommon after spinal fusion. Patient and perioperative factors were associated with continuation of prophylactic antibiotics after hospital discharge.
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Affiliation(s)
- David K. Warren
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - Katelin B. Nickel
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - Jennifer H. Han
- Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Pam Tolomeo
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher J. Hostler
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, NC, USA
- Infectious Diseases Section, Durham VA Health Care System, Durham, NC, USA
| | - Katherine Foy
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, NC, USA
| | - Ian R. Banks
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - Victoria J. Fraser
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - Margaret A. Olsen
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
- Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO, USA
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Phillips BT, Sheldon ES, Orhurhu V, Ravinsky RA, Freiser ME, Asgarzadeh M, Viswanath O, Kaye AD, Roguski M. Preoperative Versus Extended Postoperative Antimicrobial Prophylaxis of Surgical Site Infection During Spinal Surgery: A Comprehensive Systematic Review and Meta-Analysis. Adv Ther 2020; 37:2710-2733. [PMID: 32415484 PMCID: PMC7467442 DOI: 10.1007/s12325-020-01371-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Indexed: 02/07/2023]
Abstract
Introduction Surgical site infection (SSI) following spinal surgery is a major source of postoperative morbidity. Although studies have demonstrated perioperative antimicrobial prophylaxis (AMP) to be beneficial in the prevention of SSI among spinal surgery patients, consensus is lacking over whether preoperative or extended postoperative AMP is most efficacious. To date, no meta-analysis has investigated the comparative efficacy of these two temporally variable AMP protocols in spinal surgery. We undertook a systemic review and meta-analysis to determine whether extended postoperative AMP is associated with a difference in the rate of SSI occurrence among adult patients undergoing spinal surgery. Methods Embase and MEDLINE databases were systematically searched for clinical trials and cohort studies directly comparing SSI rates among adult spinal surgery patients receiving either preoperative or extended postoperative AMP. Quality of evidence of the overall study population was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group approach. Random effects meta-analyses were performed utilizing both pooled and stratified data based on instrumentation use. Results Five studies met inclusion criteria. No individual study demonstrated a significant difference in the rate of SSI occurrence between preoperative and extended postoperative AMP protocols. The GRADE quality of evidence was low. Among the overall cohort of 2824 patients, 96% underwent lumbar spinal surgery. Pooled SSI rates were 1.38% (26/1887) for patients receiving extended postoperative AMP and 1.28% (12/937) for patients only receiving preoperative AMP. The risk of SSI development among patients receiving extended postoperative AMP was not significantly different from the risk of SSI development among patients only receiving preoperative AMP [RR (risk ratio), 1.11; 95% CI (confidence interval) 0.53–2.36; p = 0.78]. The difference in risk of SSI development when comparing extended postoperative AMP to preoperative AMP was also not significant for both instrumented (RR, 0.92; 95% CI 0.15–5.75; p = 0.93) and non-instrumented spinal surgery (RR, 1.25; 95% CI 0.49–3.17; p = 0.65). There was no evidence of heterogeneity of treatment effects for all meta-analyses. Conclusion Preoperative AMP appears to provide equivalent protection against SSI development when compared to extended postoperative AMP. Prudent antibiotic use is also known to decrease hospital length of stay, healthcare expenditure, and risk of complications. However, until higher-quality evidence becomes available regarding AMP in spinal surgery, surgeons should continue to exercise discretion and clinical judgment when weighing the effects of patient comorbidities and complications before determining the optimal duration of perioperative AMP. Electronic supplementary material The online version of this article (10.1007/s12325-020-01371-5) contains supplementary material, which is available to authorized users.
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Prophylactic postoperative measures to minimize surgical site infections in spine surgery: systematic review and evidence summary. Spine J 2020; 20:435-447. [PMID: 31557586 DOI: 10.1016/j.spinee.2019.09.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 09/12/2019] [Accepted: 09/13/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND CONTEXT There are three phases in prophylaxis of surgical site infections (SSI): preoperative, intraoperative and postoperative. There is lack of consensus and paucity of evidence with SSI prophylaxis in the postoperative period. PURPOSE To systematically evaluate the literature, and provide evidence-based summaries on postoperative measures for SSI prophylaxis in spine surgery. STUDY DESIGN Systematic review, meta-analysis, evidence synthesis. METHODS A systematic review conforming to PRIMSA guidelines was performed utilizing PubMed (MEDLINE), EMBASE, and the Cochrane Database from inception to January 2019. The GRADE approach was used for quality appraisal and synthesis of evidence. Six postoperative care domains with associated key questions were identified. Included studies were extracted into evidence tables, data synthesized quantitatively and qualitatively, and evidence appraised per GRADE approach. RESULTS Forty-one studies (nine RCT, 32 cohort studies) were included. In the setting of preincisional antimicrobial prophylaxis (AMP) administration, use of postoperative AMP for SSI reduction has not been found to reduce rate of SSI in lumbosacral spine surgery. Prolonged administration of AMP for more than 48 hours postoperatively does not seem to reduce the rate of SSI in decompression-only or lumbar spine fusion surgery. Utilization of wound drainage systems in lumbosacral spine and adolescent idiopathic scoliosis corrective surgery does not seem to alter the overall rate of SSI in spine surgery. Concomitant administration of AMP in the presence of a wound drain does not seem to reduce the overall rate of SSI, deep SSI, or superficial SSI in thoracolumbar fusion performed for degenerative and deformity spine pathologies, and in adolescent idiopathic scoliosis corrective surgery. Enhanced-recovery after surgery clinical pathways and infection-specific protocols do not seem to reduce rate of SSI in spine surgery. Insufficient evidence exists for other types of spine surgery not mentioned above, and also for non-AMP pharmacological measures, dressing type and duration, suture and staple management, and postoperative nutrition for SSI prophylaxis in spine surgery. CONCLUSIONS Despite the postoperative period being key in SSI prophylaxis, the literature is sparse and without consensus on optimum postoperative care for SSI prevention in spine surgery. The current best evidence is presented with its limitations. High quality studies addressing high risk cohorts such as the elderly, obese, and diabetic populations, and for traumatic and oncological indications are urgently required.
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Ho AL, Stienen MN, Ratliff JK. Letter: Antibiotic Stewardship and Single-Dose Antibiotic Prophylaxis: A Word of Caution. Neurosurgery 2019; 86:E360-E361. [PMID: 31748799 DOI: 10.1093/neuros/nyz477] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Allen L Ho
- Department of Neurosurgery Stanford University School of Medicine Stanford, California
| | - Martin N Stienen
- Department of Neurosurgery Stanford University School of Medicine Stanford, California
| | - John K Ratliff
- Department of Neurosurgery Stanford University School of Medicine Stanford, California
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Nagata K, Yamada K, Shinozaki T, Miyazaki T, Tokimura F, Oka H, Tajiri Y, Tanaka S, Okazaki H. Non-inferior comparative study comparing one or two day antimicrobial prophylaxis after clean orthopaedic surgery (NOCOTA study): a study protocol for a cluster pseudo-randomized controlled trial comparing duration of antibiotic prophylaxis. BMC Musculoskelet Disord 2019; 20:533. [PMID: 31722700 PMCID: PMC6854781 DOI: 10.1186/s12891-019-2879-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 10/03/2019] [Indexed: 01/25/2023] Open
Abstract
Background Antimicrobial prophylaxis (AMP) is one of the most important measures for preventing surgical site infections (SSIs); however, controversies remain regarding its adequate duration. Although the World Health Organization and the Center for Disease Control and Prevention do not recommend additional AMP after closure, the American Society of Health-System Pharmacists and the Musculoskeletal Infection Society permit the use of postoperative AMP, but recommend discontinuation within 24 h. Similarly, the Japanese Society of Chemotherapy and the Japan Society for Surgical Infection also permit AMP within 24–48 h after various orthopaedic procedures. In these guidelines, recommendations regarding AMP duration were weak due to a relative lack of evidence, and currently, there is no high-quality evidence comparing AMP use within 24 h versus 24–48 h regarding orthopaedic procedures. Urinary tract infection (UTI) and respiratory tract infection (RTI) are also important health care-associated infections (HAIs) faced after surgery. Although AMP duration may affect these HAIs, its effects have not been well evaluated. Methods We have organized a multicenter, prospective, cluster pseudo-randomized controlled trial to examine the non-inferiority of shorter AMP duration (within 24 h) against longer duration (24–48 h) in preventing postoperative HAIs. Participating facilities will be divided into two groups. In Group 24, AMP will be discontinued within 24 h after surgery. In Group 48, AMP will be discontinued within 24–48 h after surgery. The group allocation will be switched every 2 months until the targeted recruitment (500 participants per group) is met. The primary outcome will be the cumulative incidence of all HAIs (SSI, UTI, RTI, and other infectious diseases), which require antibiotic therapies within 30 days after surgery. In addition to mortality and cardiovascular events, prolonged hospitalization (> 30 days) and the rate of antibiotic resistance rate of SSI pathogens will also be evaluated. Outcomes will be evaluated within 30–180 days after surgery in person by the surgeon, by mail, or by telephone survey. Data will be analyzed by a statistician not engaged in data collection. Discussion This study may provide valuable information for developing future recommendations for adequate AMP duration after clean orthopaedic surgery. Trial registration UMIN000030929, registered January 22, 2018.
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Affiliation(s)
- Kosei Nagata
- Department of Orthopaedic Surgery and Spinal Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Koji Yamada
- Department of Orthopedic Surgery, Japan Organization of Occupational Health and Safety Kanto Rosai Hospital, 1-1 Kizukisumiyoshi-cho, Nakahara-ku, Kawasaki City, Kanagawa Prefecture, 211-8510, Japan.
| | - Tomohiro Shinozaki
- Department of Information and Computer Technology, Faculty of Engineering, Tokyo University of Science, Tokyo, Japan
| | - Tsuyoshi Miyazaki
- Department of Orthopedic Surgery, Tokyo Metropolitan Geriatric Hospital and institute of Gerontology, Tokyo, Japan
| | - Fumiaki Tokimura
- Department of Orthopedic Surgery, Tokyo Metropolitan Geriatric Hospital and institute of Gerontology, Tokyo, Japan
| | - Hiroyuki Oka
- Department of Medical Research and Management for Musculoskeletal Pain, 22nd Century Medical and Research Center, Faculty of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Yasuhito Tajiri
- Department of Orthopedic Surgery, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Sakae Tanaka
- Department of Orthopaedic Surgery and Spinal Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Hiroshi Okazaki
- Department of Orthopedic Surgery, Japan Organization of Occupational Health and Safety Kanto Rosai Hospital, 1-1 Kizukisumiyoshi-cho, Nakahara-ku, Kawasaki City, Kanagawa Prefecture, 211-8510, Japan
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Maciejczak A, Wolan-Nieroda A, Wałaszek M, Kołpa M, Wolak Z. Antibiotic prophylaxis in spine surgery: a comparison of single-dose and 72-hour protocols. J Hosp Infect 2019; 103:303-310. [DOI: 10.1016/j.jhin.2019.04.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 04/24/2019] [Indexed: 10/26/2022]
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Urquhart JC, Collings D, Nutt L, Kuska L, Gurr KR, Siddiqi F, Rasoulinejad P, Fleming A, Collie J, Bailey CS. The Effect of Prolonged Postoperative Antibiotic Administration on the Rate of Infection in Patients Undergoing Posterior Spinal Surgery Requiring a Closed-Suction Drain: A Randomized Controlled Trial. J Bone Joint Surg Am 2019; 101:1732-1740. [PMID: 31577678 DOI: 10.2106/jbjs.19.00009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Closed-suction drains are frequently used following posterior spinal surgery. The optimal timing of antibiotic discontinuation in this population may influence infection risk, but there is a paucity of evidence. The aim of this study was to determine whether postoperative antibiotic administration for 72 hours (24 hours after drain removal as drains were removed on the second postoperative day) decreases the incidence of surgical site infection compared with postoperative antibiotic administration for 24 hours. METHODS Patients undergoing posterior thoracolumbar spinal surgery managed with a closed-suction drain were prospectively randomized into 1 of 2 groups of postoperative antibiotic durations: (1) 24 hours, or (2) 24 hours after drain removal (72 hours). Drains were discontinued on the second postoperative day. The duration of antibiotic administration was not blinded. All subjects received a single dose of preoperative antibiotics, as well as intraoperative antibiotics if the surgical procedure lasted >4 hours. The primary outcome was the rate of complicated surgical site infection (deep or organ or space) within 1 year of the surgical procedure. RESULTS The trial was terminated at an interim analysis, when 552 patients were enrolled, for futility with respect to the primary outcome. In this study, 282 patients were randomized to postoperative antibiotics for 24 hours and 270 patients were randomized to postoperative antibiotics for 72 hours. A complicated infection developed in 17 patients (6.0%) in the 24-hour group and in 14 patients (5.2%) in the 72-hour group (p = 0.714). The superficial infection rate did not differ between the groups (p = 0.654): 9.6% in the 24-hour group compared with 8.1% in the 72-hour group. Patients in the 72-hour group had a median hospital stay that was 1 day longer (p < 0.001). At 1 year, patient-rated outcomes including leg and back pain and physical and mental functioning were not different between the groups. CONCLUSIONS The extension of postoperative antibiotics for 72 hours, when a closed-suction drain is required, was not associated with a reduction in the rate of complicated surgical site infection after posterior thoracolumbar spinal surgery. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of Levels of Evidence.
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Affiliation(s)
- Jennifer C Urquhart
- Combined Orthopaedic and Neurosurgical Spine Program, London Health Sciences Centre, London, Ontario, Canada.,Lawson Health Research Institute, London, Ontario, Canada
| | - Darryl Collings
- Division of Orthopaedics, Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Lori Nutt
- Combined Orthopaedic and Neurosurgical Spine Program, London Health Sciences Centre, London, Ontario, Canada
| | - Linda Kuska
- Combined Orthopaedic and Neurosurgical Spine Program, London Health Sciences Centre, London, Ontario, Canada
| | - Kevin R Gurr
- Combined Orthopaedic and Neurosurgical Spine Program, London Health Sciences Centre, London, Ontario, Canada.,Lawson Health Research Institute, London, Ontario, Canada.,Division of Orthopaedics, Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Fawaz Siddiqi
- Combined Orthopaedic and Neurosurgical Spine Program, London Health Sciences Centre, London, Ontario, Canada.,Lawson Health Research Institute, London, Ontario, Canada.,Division of Orthopaedics, Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Parham Rasoulinejad
- Combined Orthopaedic and Neurosurgical Spine Program, London Health Sciences Centre, London, Ontario, Canada.,Lawson Health Research Institute, London, Ontario, Canada.,Division of Orthopaedics, Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Alyssa Fleming
- Lawson Health Research Institute, London, Ontario, Canada
| | - Joanne Collie
- Lawson Health Research Institute, London, Ontario, Canada
| | - Christopher S Bailey
- Combined Orthopaedic and Neurosurgical Spine Program, London Health Sciences Centre, London, Ontario, Canada.,Lawson Health Research Institute, London, Ontario, Canada.,Division of Orthopaedics, Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
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Wyles CC, Vargas-Hernandez JS, Carlson SW, Carlson BC, Sierra RJ. Single-Dose Perioperative Antibiotics Do Not Increase the Risk of Surgical Site Infection in Unicompartmental Knee Arthroplasty. J Arthroplasty 2019; 34:S327-S330. [PMID: 30910245 DOI: 10.1016/j.arth.2019.02.041] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 02/08/2019] [Accepted: 02/19/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Unicompartmental knee arthroplasty (UKA) is commonly performed as an outpatient procedure. To facilitate this process, a single-dose intravenous (IV) perioperative antibiotic administration is required compared to 24-hour IV antibiotic dosing schedules that are typical of most inpatient arthroplasty procedures. There is a paucity of literature to guide surgeons on the safety of single-dose perioperative antibiotic administration for arthroplasty procedures, particularly those that will be performed in the outpatient setting. The purpose of this study is to evaluate a large series of UKA performed with single-dose vs 24-hour IV antibiotic coverage to determine the impact on risk for surgical site infection (SSI). METHODS All UKA cases were evaluated from 2007 to 2017 performed by a single surgeon at an academic institution. There were 296 UKAs in the cohort: 40 were outpatient procedures receiving single-dose antibiotics and 256 were inpatient procedures receiving 24-hour antibiotics. No patients were prescribed adjuvant oral antibiotics. Mean age was 64 years, 50% were female, mean body mass index was 32 kg/m2, and mean follow-up was 4.1 years (range 1.0-10.4). Perioperative antibiotic regimen was evaluated and SSI, defined as occurring within 1 year of surgery, was abstracted through a prospective total joint registry and manual chart review. RESULTS SSI occurred in 2 of 296 cases (0.7%) in the entire cohort, 2 of 256 inpatient UKAs (0.8%), and 0 of 40 outpatient UKAs (0%) (P = 1.00). One SSI was a deep infection occurring 6 weeks postoperatively that required 2-stage exchange and conversion to total knee arthroplasty. The other was a superficial infection treated with 2 weeks of oral antibiotics. CONCLUSION This study demonstrates a low SSI risk (0.8% or less) following UKA with both single-dose and 24-hour IV antibiotics. Administering single-dose perioperative antibiotics is safe for UKA, which should alleviate that potential concern for outpatient surgery. LEVEL OF EVIDENCE Level III, Therapeutic.
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Affiliation(s)
- Cody C Wyles
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, 55905
| | | | - Samuel W Carlson
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, 55905
| | - Bayard C Carlson
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, 55905
| | - Rafael J Sierra
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, 55905
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Ryan SP, Kildow BJ, Tan TL, Parvizi J, Bolognesi MP, Seyler TM. Is There a Difference in Infection Risk Between Single and Multiple Doses of Prophylactic Antibiotics? A Meta-analysis. Clin Orthop Relat Res 2019; 477:1577-1590. [PMID: 30811357 PMCID: PMC6999965 DOI: 10.1097/corr.0000000000000619] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 12/04/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND The prevention of surgical site infection guidelines issued by the Centers for Disease Control and Prevention (CDC) recently recommended that only a single dose of preoperative antibiotics be administered to patients undergoing clean-contaminated procedures based on data from a variety of surgical disciplines. For orthopaedic procedures, where postoperative infections can have significant consequences, the existing evidence for this recommendation is widely debated. QUESTIONS/PURPOSES Is there a difference in postoperative infection risk when utilizing a single dose of preoperative antibiotics compared with multiple doses of perioperative antibiotics for orthopaedic procedures where implants are placed? METHODS MEDLINE, EMBASE, Google Scholar, and Cochrane were systematically reviewed for randomized controlled trials (RCTs) of a single dose of preoperative antibiotics compared with pre- and postoperative prophylaxis from 1980 to 2017 for all orthopaedic procedures where implants were being placed. Infection (both superficial and deep) as a primary outcome through all available followup was required for inclusion. Fourteen RCTs detailing 9691 orthopaedic procedures were included for analysis, including seven arthroplasty, one spine, and six general orthopaedic trials (two specific to hip fracture fixation). Pooled infection outcomes were analyzed with random-effects modeling in light of study heterogeneity. Bias was evaluated using the Cochrane risk of bias tool as well as a funnel plot for publication bias, and quality of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Bias was largely uncertain; however, a high risk of bias was noted in four studies. No significant overall publication bias was noted. The quality of evidence was determined to be very low based on the GRADE tool, downgraded based on risk of bias, inconsistency, and imprecision. Despite the quality of evidence, the data were pooled in light of the current recommendations from the CDC to critically evaluate the recommendation that a single dose of antibiotics be utilized. RESULTS There were no differences in infection risk between single- versus multiple-dose groups (single: 83 of 4263 [2%], multiple: 101 of 5428 [2%]; odds ratio, 0.92 [95% confidence interval, 0.56-1.51]; p = 0.740, I = 36% for statistical heterogeneity). CONCLUSIONS There is no difference in infection risk between a single dose and multiple doses of perioperative antibiotics for orthopaedic procedures where implants are utilized, consistent with recent recommendations. However, the quality of evidence for orthopaedic procedures is low, and a randomized study with a sufficient sample size is needed to examine the issue before universal adoption of a single antibiotic dose. LEVEL OF EVIDENCE Level I, therapeutic study.
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Affiliation(s)
- Sean P Ryan
- S. P. Ryan, B. J. Kildow, M. P. Bolognesi, T. M. Seyler, Duke University Hospital, Durham, NC, USA T. L. Tan, J. Parvizi, Rothman Institute, Philadelphia, PA, USA
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Tan TL, Shohat N, Rondon AJ, Foltz C, Goswami K, Ryan SP, Seyler TM, Parvizi J. Perioperative Antibiotic Prophylaxis in Total Joint Arthroplasty: A Single Dose Is as Effective as Multiple Doses. J Bone Joint Surg Am 2019; 101:429-437. [PMID: 30845037 DOI: 10.2106/jbjs.18.00336] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Recent surgical site infection prevention guidelines recommend that no additional prophylactic antibiotics be administered after the surgical incision is closed in clean-contaminated procedures. Although there is ample evidence to support this recommendation in non-arthroplasty surgery, there is concern about extending these guidelines to surgical procedures with an implant such as total joint arthroplasty (TJA). The aim of this study was to compare the efficacy of a single dose of prophylactic antibiotics with that of multiple doses of antibiotics for prevention of periprosthetic joint infection (PJI) in patients undergoing TJA. METHODS A retrospective study of 20,682 primary TJAs carried out from 2006 to 2017 was performed. Patients who received a single dose of prophylactic antibiotics (n = 4,523) were compared with patients who received multiple doses of antibiotics (n = 16,159). A previously validated PJI risk score was assigned to each patient. Patients who developed PJI within 1 year were identified, and a multivariate logistic regression analysis was performed to control for potential confounders. Analyses using propensity score matching and regression adjustment were also performed. RESULTS The overall PJI rate was 0.60% (27 of 4,523) for patients who received a single dose of antibiotics compared with 0.88% (142 of 16,159) for those who received multiple doses. There was no difference in the PJI rate between patients who received a single dose of antibiotics and those who received multiple doses in the univariate (adjusted odds ratio [OR] = 0.674, p = 0.064), multivariate (OR = 0.755, p = 0.205), or propensity score matched analysis (OR = 0.746, p = 0.277). Furthermore, multiple doses did not demonstrate any additional benefit for patients with a high preoperative risk of PJI (p = 0.136). CONCLUSIONS This study supports the notion that the administration of additional antibiotics following skin closure may not be required for primary TJA, regardless of the patient's preoperative risk of PJI. The findings of this large retrospective study highlight the need for a randomized, prospective study on which to base guidelines. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Timothy L Tan
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Noam Shohat
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Alexander J Rondon
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Carol Foltz
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Karan Goswami
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Sean P Ryan
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Thorsten M Seyler
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Javad Parvizi
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Hip and Knee Section, Prevention, Antimicrobials (Systemic): Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S279-S288. [PMID: 30348572 DOI: 10.1016/j.arth.2018.09.012] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Yilmaz E, Tawfik T, O'Lynnger TM, Iwanaga J, Blecher R, Abdul-Jabbar A, Tubbs RS, Schmidt CK, Oskouian RJ, Chapman J. Wound Closure After Posterior Multi-level Lumbar Spine Surgery: An Anatomical Cadaver Study and Technical Note. Cureus 2018; 10:e3595. [PMID: 30675448 PMCID: PMC6336212 DOI: 10.7759/cureus.3595] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Meticulous attention to wound closure in posterior lumbar spine surgery is an important principle in reducing surgical site infections. We detail standardized wound closure used for posterior lumbar spine surgery at a tertiary care referral center and illustrate this as a step-by-step cadaveric dissection. The lumbar spine of a cadaveric specimen (male, 73 years at death) was used for dissection. Standardizing wound closure in posterior lumbar spine surgery may help limit wound complications and infection. Some key points of our technique, as demonstrated on a cadaveric specimen, include separating fascial compartments, avoiding suture abscesses, and creating a tension-free wound.
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Affiliation(s)
- Emre Yilmaz
- Surgery, Swedish Neuroscience Institute, Seattle, USA
| | - Tamir Tawfik
- Neurosurgery, Swedish Neuroscience Institute, Seattle, USA
| | | | - Joe Iwanaga
- Medical Education and Simulation, Seattle Science Foundation, Seattle, USA
| | - Ronen Blecher
- Neurosurgery, Swedish Neuroscience Institute, Seattle, USA
| | | | - R Shane Tubbs
- Neurosurgery, Seattle Science Foundation, Seattle, USA
| | | | - Rod J Oskouian
- Neurosurgery, Swedish Neuroscience Institute, Seattle, USA
| | - Jens Chapman
- Neurosurgery, Swedish Neuroscience Institute, Seattle, USA
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Yao R, Tan T, Tee JW, Street J. Prophylaxis of surgical site infection in adult spine surgery: A systematic review. J Clin Neurosci 2018; 52:5-25. [DOI: 10.1016/j.jocn.2018.03.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 03/12/2018] [Indexed: 01/27/2023]
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Andrés-Cano P, Cerván A, Rodríguez-Solera M, Antonio Ortega J, Rebollo N, Guerado E. Surgical Infection after Posterolateral Lumbar Spine Arthrodesis: CT Analysis of Spinal Fusion. Orthop Surg 2018; 10:89-97. [PMID: 29770586 DOI: 10.1111/os.12371] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 01/20/2018] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To determine the incidence of infection after instrumented lumbar spine surgery, the demographic and surgical variables associated with acute infection, and the influence of infection and debridement on the consolidation of spinal fusion. METHODS After obtaining approval from the hospital ethics committee, an observational study was made on a prospective cohort of consecutive patients surgically treated by posterolateral lumbar spine arthrodesis (n = 139, 2005-2011). In all cases, the minimum follow-up period was 18 months. The following bivariate analysis was conducted of demographic and surgical variables: non-infection group (n = 123); infection group (n = 16). Fusion rates were determined by multislice CT. Logistic regression analysis was performed. RESULTS Incidence of deep infection requiring debridement: 11.51% (95% confidence interval, 5.85-17.18]). Bivariate analysis: differences were observed in hospital stay (7.0 days [range, 4-10] vs 14.50 days [range, 5.25-33.75]; P = 0.013), surgical time (3.15 h vs 4.09 h; P = 0.004), body mass index (25.11 kg/m2 [22.58-27.0] vs 26.02 kg/m2 [24.15 to 29.38]; P = 0.043), Charlson comorbidity index (median, 0 vs 1; P = 0.027), and rate of unsuccessful consolidation according to CT (18.4% vs 72.7%; P = 0.0001). In a model of multivariate logistic regression, taking as the dependent variable unsuccessful arthrodesis after 1 year, and adjusting for the other independent variables (infection, body mass index, Charlson comorbidity index, and surgical time), the only variable that was significantly associated with an outcome of unsuccessful spinal fusion after 1 year was infection, with OR = 12.44 (95% confidence interval, 2.50-61.76). CONCLUSION Deep infection after instrumented lumbar spine arthrodesis is a common complication that compromises the radiographic outcome of surgery. Patients who develop a postoperative infection and require debridement surgery are 12 times less likely to achieve satisfactory radiological fusion.
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Affiliation(s)
- Pablo Andrés-Cano
- Orthopaedic Surgery and Traumatology Department, Hospital Costa del Sol, Marbella, Spain.,Orthopaedic Surgery and Traumatology Department, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Ana Cerván
- Orthopaedic Surgery and Traumatology Department, Hospital Costa del Sol, Marbella, Spain
| | | | - Jose Antonio Ortega
- Orthopaedic Surgery and Traumatology Department, Hospital Costa del Sol, Marbella, Spain
| | | | - Enrique Guerado
- Orthopaedic Surgery and Traumatology Department, Hospital Costa del Sol, Marbella, Spain
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Allegranzi B, Zayed B, Bischoff P, Kubilay NZ, de Jonge S, de Vries F, Gomes SM, Gans S, Wallert ED, Wu X, Abbas M, Boermeester MA, Dellinger EP, Egger M, Gastmeier P, Guirao X, Ren J, Pittet D, Solomkin JS. New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective. THE LANCET. INFECTIOUS DISEASES 2016; 16:e288-e303. [PMID: 27816414 DOI: 10.1016/s1473-3099(16)30402-9] [Citation(s) in RCA: 476] [Impact Index Per Article: 59.5] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 08/28/2016] [Accepted: 09/13/2016] [Indexed: 12/11/2022]
Abstract
Surgical site infections (SSIs) are the most common health-care-associated infections in developing countries, but they also represent a substantial epidemiological burden in high-income countries. The prevention of these infections is complex and requires the integration of a range of preventive measures before, during, and after surgery. No international guidelines are available and inconsistencies in the interpretation of evidence and recommendations in national guidelines have been identified. Considering the prevention of SSIs as a priority for patient safety, WHO has developed evidence-based and expert consensus-based recommendations on the basis of an extensive list of preventive measures. We present in this Review 16 recommendations specific to the intraoperative and postoperative periods. The WHO recommendations were developed with a global perspective and they take into account the balance between benefits and harms, the evidence quality level, cost and resource use implications, and patient values and preferences.
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Affiliation(s)
- Benedetta Allegranzi
- Infection Prevention and Control Global Unit, Service Delivery and Safety, WHO, Geneva, Switzerland.
| | - Bassim Zayed
- Infection Prevention and Control Global Unit, Service Delivery and Safety, WHO, Geneva, Switzerland
| | - Peter Bischoff
- Institute of Hygiene and Environmental Medicine, Charité-University Medicine, Berlin, Germany
| | - N Zeynep Kubilay
- Infection Prevention and Control Global Unit, Service Delivery and Safety, WHO, Geneva, Switzerland
| | - Stijn de Jonge
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | - Fleur de Vries
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | | | - Sarah Gans
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | - Elon D Wallert
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | - Xiuwen Wu
- Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Mohamed Abbas
- Infection Control Programme, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Marja A Boermeester
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | | | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Petra Gastmeier
- Institute of Hygiene and Environmental Medicine, Charité-University Medicine, Berlin, Germany
| | | | - Jianan Ren
- Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Didier Pittet
- Infection Control Programme, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland; WHO Collaborating Centre on Patient Safety (Infection Control and Improving Practices), University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Joseph S Solomkin
- OASIS Global, Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Jacob Júnior C, de Assis AC, Guimarães RG, Barbosa IM, Batista Júnior JL. Postoperative comparison of the results from use of antibiotic prophylaxis for one and five days among patients undergoing lumbar arthrodesis. Rev Bras Ortop 2016; 51:333-6. [PMID: 27274488 PMCID: PMC4887444 DOI: 10.1016/j.rboe.2016.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 08/18/2015] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To compare the postoperative results from use of antibiotic prophylaxis for one and five days among patients undergoing lumbar arthrodesis at up to three levels. METHODS Forty-three patients who all underwent lumbar arthrodesis due to degenerative disc disease at one, two or three levels were evaluated. They were divided randomly into two groups: one received antibiotic prophylaxis with cefalotin (1 g) and the other received the same antibiotic for five days. After the surgical intervention, the patients were evaluated at the time of hospital discharge, at the first return to the clinic (two weeks later) and 90 days after the date of the surgery with the surgical wound, with clinical examination of the surgical wound and laboratory tests on both groups. RESULTS It was observed that among the patients in the group with one day of antibiotic prophylaxis, 28.6% presented complications in the surgical wound, while in the group with five days, 27.9% presented complications. CONCLUSION This study demonstrates that a single dose of antibiotic prophylaxis is as effective as a regimen of multiple doses in lumbar arthrodesis surgery at up to three levels. Thus, the costs and risks of subjecting patients to hospitalization under a prolonged drug regimen are unjustifiable.
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Comparação pós‐operatória dos resultados do uso de antibioticoprofilaxia por um e cinco dias em pacientes submetidos à artrodese lombar. Rev Bras Ortop 2016. [DOI: 10.1016/j.rbo.2015.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Antimicrobial prophylaxis to prevent surgical site infection in adolescent idiopathic scoliosis patients undergoing posterior spinal fusion: 2 doses versus antibiotics till drain removal. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 25:3242-3248. [DOI: 10.1007/s00586-016-4491-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 02/22/2016] [Accepted: 02/23/2016] [Indexed: 12/19/2022]
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Latka D, Miekisiak G, Jarmuzek P, Lachowski M, Kaczmarczyk J. Treatment of lumbar disc herniation with radiculopathy. Clinical practice guidelines endorsed by The Polish Society of Spinal Surgery. Neurol Neurochir Pol 2015; 50:101-8. [PMID: 26969566 DOI: 10.1016/j.pjnns.2015.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 12/02/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Herniated lumbar disc (HLD) is arguably the most common spinal disorder requiring surgical intervention. Although the term is fairly straightforward, the exact pathology and thus the clinical picture and natural history may vary. Therefore, it is immensely difficult to formulate universal guidelines for surgical treatment. AIM The aim of this paper is to organize the terminology and clear the inconsistencies in phraseology, review treatment options and gather available published evidence to address the clinical questions to create a set of clinical guidelines in relevant to the topic. METHODS AND RESULTS Twelve queries, addressing optimal surgical treatment of the HLD have been formulated. The results, based on the literature review are described in the present work. The final product of the analysis was a set of guidelines for the surgical treatment of symptomatic HLD. Categorized into four tiers based on the level of evidence (I-III and X), they have been designed to assist in the selection of optimal, effective treatment leading to the successful outcome. CONCLUSIONS The evidence based medicine (EBM) is becoming ever more popular among spinal surgeons. Unfortunately this is not always feasible. Lack of uniform guidelines and numerous conflicts of interest introduce flaws in the decision making process. The key role of experts and professional societies is to provide high value recommendation based on the most current literature. Present work contains a set of guidelines for the surgical treatment of HLD officially endorsed by the Polish Spine Surgery Society.
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Affiliation(s)
- Dariusz Latka
- Department of Neurosurgery, Regional Medical Center, Opole, Poland.
| | - Grzegorz Miekisiak
- Department of Neurosurgery, Specialist Medical Center, Polanica-Zdroj, Poland
| | - Pawel Jarmuzek
- Department of Neurosurgery, Regional Neurosurgery and Neurotrauma Center, Zielona Gora, Poland
| | | | - Jacek Kaczmarczyk
- Department of Orthopedics and Traumatology, Poznan University of Medical Sciences, Poznan, Poland
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Oksuz E, Deniz FE, Gunal O, Demir O, Barut S, Markoc F, Erkorkmaz U. Which method is the most effective for preventing postoperative infection in spinal surgery? EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 25:1006-11. [PMID: 25893337 DOI: 10.1007/s00586-015-3941-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 04/07/2015] [Accepted: 04/07/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND Several methods have been used to reduce the infection rate in spinal surgeries with instrumentation. PURPOSE Which method is the most effective for preventing postoperative infection? STUDY DESIGN Basic science, animal model. OBJECTIVE In the present study, the efficiency of antibiotic prophylaxis, silver-plated screws, and local rifamycin application to the surgical site was investigated in an experimental animal model. Staphylococcus aureus was used as the pathogen. METHODS Fifty 6-month-old female Wistar albino rats were used. The animals were randomly numbered and divided into five groups of ten rats each (Group 1, control group; Group 2, titanium screw and S. aureus inoculation; Group 3, titanium screw, 0.1 ml rifamycin application to the surgical area, and bacterial inoculation; Group 4, titanium screw, single preoperative dose of IM cefazolin, and bacterial inoculation; Group 5, silver-plated screw and bacterial inoculation). Titanium micro-screws were placed into the pedicles. The control group received a sterile isotonic solution, and the other four groups received bacterial suspensions containing S. aureus. The animals were killed 15 days later. RESULTS Intensive S. aureus growth was observed in all tissue and screw samples from Group 2. The results for Group 3 were similar to those for Group 1, no growth was observed in the screw cultures. Intensive growth was observed in the five screw samples in Group 4 and in the eight samples in Group 5. CONCLUSION Our study suggests that rifamycin application to the surgical area in spinal operations with instrumentation is an effective method to prevent S. aureus infections.
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Affiliation(s)
- Erol Oksuz
- Department of Neurosurgery, Gaziosmanpasa University, Tokat, Turkey. .,, Kaşıkcıbagları m. Ahmet Yesevi c., 8. Sok. No: 3, 60000, Merkez, Tokat, Turkey.
| | | | - Ozgur Gunal
- Department of Infectious Diseases and Clinical Microbiology, Gaziosmanpasa University, Tokat, Turkey
| | - Ozgur Demir
- Department of Neurosurgery, Gaziosmanpasa University, Tokat, Turkey
| | - Sener Barut
- Department of Infectious Diseases and Clinical Microbiology, Gaziosmanpasa University, Tokat, Turkey
| | - Fatma Markoc
- Department of Pathology, Gaziosmanpasa University, Tokat, Turkey
| | - Unal Erkorkmaz
- Department of Statistics, Sakarya University, Sakarya, Turkey
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Reutter F, Reuter DA, Hilgarth H, Heilek AM, Goepfert MS, Punke MA. [Perioperative antibiotic prophylaxis]. Anaesthesist 2015; 63:73-86. [PMID: 24402512 DOI: 10.1007/s00101-013-2282-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In times of growing bacterial resistance against antimicrobiotic drugs the broad prescription of antibiotics in human medicine must be carefully considered. The perioperative antibiotic treatment is in the center of that conflict. On the one hand an efficient pathogen reduction for the preemptive treatment of infectious complications is desired but on the other hand it is suspected that this promotes the selection of multiresistant pathogens which could lead to an increase of more complicated nosocomial infections. The aim of this article is a critical appraisal of this subject on the basis of the 2012 guidelines of the German working group of Hygiene in Hospital and Practice (AWMF) and the 2010 recommendations of the Paul-Ehrlich-Gesellschaft.
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Affiliation(s)
- F Reutter
- Zentrum für Anästhesiologie und Intensivmedizin, Klinik und Poliklinik für Anästhesiologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
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Single Dose Antibiotic Prophylaxis in Lumbar Stenosis or Disc Surgery: A Review of 117 Cases. ARCHIVES OF NEUROSCIENCE 2014. [DOI: 10.5812/archneurosci.15055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Kasliwal MK, Tan LA, Traynelis VC. Infection with spinal instrumentation: Review of pathogenesis, diagnosis, prevention, and management. Surg Neurol Int 2013; 4:S392-403. [PMID: 24340238 PMCID: PMC3841941 DOI: 10.4103/2152-7806.120783] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 06/06/2013] [Indexed: 12/12/2022] Open
Abstract
Background: Instrumentation has become an integral component in the management of various spinal pathologies. The rate of infection varies from 2% to 20% of all instrumented spinal procedures. Every occurrence produces patient morbidity, which may adversely affect long-term outcome and increases health care costs. Methods: A comprehensive review of the literature from 1990 to 2012 was performed utilizing PubMed and several key words: Infection, spine, instrumentation, implant, management, and biofilms. Articles that provided a current review of the pathogenesis, diagnosis, prevention, and management of instrumented spinal infections over the years were reviewed. Results: There are multiple risk factors for postoperative spinal infections. Infections in the setting of instrumentation are more difficult to diagnose and treat due to biofilm. Infections may be early or delayed. C Reactive Protein (CRP) and Magnetic Resonance Imaging (MRI) are important diagnostic tools. Optimal results are obtained with surgical debridement followed by parenteral antibiotics. Removal or replacement of hardware should be considered in delayed infections. Conclusions: An improved understanding of the role of biofilm and the development of newer spinal implants has provided insight in the pathogenesis and management of infected spinal implants. This literature review highlights the mechanism, pathogenesis, prevention, and management of infection after spinal instrumentation. It is important to accurately identify and treat postoperative spinal infections. The treatment is often multimodal and prolonged.
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Affiliation(s)
- Manish K Kasliwal
- Department of Neurosurgery, RUSH University Medical Center Chicago, IL, USA
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