Single versus multiple dose antibiotic prophylaxis in lumbar disc surgery

Interventional Therapy and Surgical Management of Lumbar Disc Herniation in Spine Surgery: A Narrative Review

Significant advancements in lumbar disc herniation (LDH) management have been made in interventional pain therapy, operative therapy, peri-operative management, and cost analysis of various procedures. The present review aims to provide a concise narrative of all these topics, current trends, and possible future directions in the management of LDH. Interventional pain management using intradiscal injections often serves as a minimally invasive non-surgical approach. Surgical modalities vary, including traditional open laminectomy, microdiscectomy, endoscopic discectomy, tubular discectomy, percutaneous laser disc decompression, and transforaminal foraminotomy. Prevention of infections during surgery is paramount and is often done via a single-dose preoperative antibiotic prophylaxis. Recurrence of LDH post-surgery is commonly observed and thus mitigative strategies for prevention have been proposed including the use of annular closure devices. Finally, all treatments are well-associated with clear as well as hidden costs to the health system and society as described by billing codes and loss of patients' quality-adjusted life-years. Our summary of recent literature regarding LDH may allow physicians to employ up-to-date evidence-based practice in clinical settings and can help drive future advancements in LDH management. Future longitudinal and comprehensive studies elucidating how each type of treatments fare against different types of herniations are warranted.

Is the routine use of systemic antibiotics after spine surgery warranted? A systematic review and meta-analysis

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.

Effectiveness of Oral Antibiotic Therapy in Prevention of Postoperative Wound Infection Requiring Surgical Washout In Spine Surgery

BACKGROUND

Surgical site infections (SSIs) after spine surgery are a significant cause of morbidity. Surgeons often prescribe oral antibiotics in the postoperative setting for infected-appearing wounds to prevent reoperation for infection; however, the efficacy of this practice has not been well studied.

METHODS

Neurosurgical spine patients with clinical concerns for SSI at the University of Pennsylvania were retrospectively studied from 2014 to 2018. Clinical predictors of 90-day reoperation for infection despite antibiotic treatment and variables that influenced antibiotic prescription were analyzed.

RESULTS

Three hundred and ninety-two patients were included in the study. Preoperative albumin level, days elapsed to antibiotic prescription from index surgery, preoperative hemoglobin level, surgical location, gender, discharge disposition, and level of wound concern were significant predictors of reoperation for infection on bivariate analysis. Days elapsed to antibiotic prescription, surgical location, and level of wound concern remained significant after multivariable logistic regression. Variables that significantly predicted prescription of an antibiotic include length of stay, cerebrospinal fluid leak, race, and level of wound concern. Length of stay, race, and level of wound concern remained significant after multivariable analysis.

CONCLUSIONS

Wound infection remains a challenging problem in spine surgery and it is reasonable to perform early reoperation in patients with high clinical concerns for infection, because bacterial isolates are often resistant to common oral antibiotics. Patients with wounds with low clinical concerns for infection may undergo a trial of oral antibiotics; however, duration of treatment should not be prolonged.

Single-dose antibiotic prophylaxis compared with multiple-dose protocol in clean pediatric neurosurgical interventions: a nonrandomized, historically controlled equivalence trial

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.

Antimicrobial prophylaxis in noninstrumented spine surgery: a prospective study to determine efficacy and drawbacks

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.

Perioperative antibiotic prophylaxis in spinal surgery

Study design: Complete audit cycle. Introduction: To highlight the unjustified overuse of perioperative antibiotics in clean non-instrumented lumbar spinal surgeries. To convince orthopedic surgeons in a methodological way of local field comparison between common practice on the use of perioperative antibiotics prophylaxis (PAP) in clean non-instrumented lumbar spinal surgeries and the ideal practice according to “The guidelines published by North American Spine Society (NASS)”. Methods: A complete audit cycle had been done. One hundred and eight patients underwent clean non-instrumented lumbar spinal surgeries in a tertiary spine center, during the period from the 1st of April to the 31st of June 2017 (primary audit period) and during the period from the 8th of May to the 21st of November 2018 (re-audit period). Group I: audit group (n = 54) was given the usual regimen (IV first-generation cephalosporin for 1–6 days, followed by oral antibiotics, till the removal of stitches) and Group II: re-audit group (n = 54) received only the IV antibiotics for one day). The study protocol was approved by our institution’s Ethical Committee (17100582). Results: This study showed a wide gap between international standards and local prescribing practices and calls for multiple interventions to improve our practice. Out of the 108 patients, only one case (1.85%) developed surgical site infection (SSI) in the audit group (Group I). The difference in infection rates between the two groups was statistically insignificant. Conclusion: A single-day postoperative dose of antibiotics effectively prevents postoperative wound infection following non-instrumented lumbar spinal surgery and is not associated with a higher infection rate.

Postoperative Prophylactic Antibiotics in Spine Surgery: A Propensity-Matched Analysis

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.

Preoperative Versus Extended Postoperative Antimicrobial Prophylaxis of Surgical Site Infection During Spinal Surgery: A Comprehensive Systematic Review and Meta-Analysis

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.

Prophylactic postoperative measures to minimize surgical site infections in spine surgery: systematic review and evidence summary

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.

Perioperative Antibiotic Prophylaxis in Total Joint Arthroplasty: A Single Dose Is as Effective as Multiple Doses

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.

Prevention of Infection in Foot and Ankle Surgery

The literature for prevention of surgical infection related primarily to foot and ankle surgery is sparse, with most attention on total joint replacement and abdominal surgery. Attention should be paid to preoperative, intraoperative, and postoperative elements, which can have an effect on the development of postoperative infection. Although antibiotic prophylaxis typically is discussed in isolation, inclusion of this step into the process enhances the overall evaluation of surgery with respect to infection. This evolution provides for better patient outcomes and decreases the likelihood of an infection incurred after foot and ankle surgery.

The Difference in Surgical Site Infection Rates Between Open and Minimally Invasive Spine Surgery for Degenerative Lumbar Pathology: A Retrospective Single Center Experience of 1442 Cases

BACKGROUND

Surgical site infection (SSI) in spinal surgery contributes to significant morbidity and healthcare resource utilization. Few studies have directly compared the rate of minimally invasive surgery (MIS) SSI with open surgery.

OBJECTIVE

To investigate whether MIS techniques had a lower SSI rate in degenerative lumbar procedures as compared with traditional open techniques.

METHODS

A single-center, retrospective review of a prospectively collected database was queried from January 2013 to 2016 for adult patients who underwent lumbar decompression and/or instrumented fusion for which the surgical indication involved degenerative disease. The SSI rate was determined for all procedures as well as in the open and minimally invasive groups. Risk factors associated with SSI were also reviewed for each patient.

RESULTS

A total of 1442 lumbar spinal procedures were performed during this time period. Of these, there were 961 MIS and 481 open (67% vs 33%, respectively). The overall SSI rate was 1.5% (21/1442). The surgical site infection rate for MIS was less than open techniques (0.5% vs 3.3%; P = .0003). For decompression only, the infection rate for MIS and open was 0.4% vs 3.9% (P = .04), and for decompression with fusion it was 0.7% vs 2.6%, respectively (P = .68).

CONCLUSION

Our study demonstrates a significant 7-fold reduction in SSIs when comparing MIS with open surgery. This significance was also demonstrated with a 10-fold reduction for procedures involving decompression alone. Procedures that require fusion as well as decompression showed a trend towards a decreased infection rate that did not reach clinical significance.

Risk factors for surgical site infections among 1,772 patients operated on for lumbar disc herniation: a multicentre observational registry-based study

BACKGROUND

There are no previous studies evaluating risk factors for surgical site infections (SSIs) and the effectiveness of prophylactic antibiotic treatment (PAT), specifically for patients operated on for lumbar disc herniation.

METHOD

This observational multicentre study comprises a cohort of 1,772 consecutive patients operated on for lumbar disc herniation without laminectomy or fusion at 23 different surgical units in Norway. The patients were interviewed about SSIs according to a standardised questionnaire at 3 months' follow-up.

RESULTS

Three months after surgery, 2.3% of the patients had an SSI. Only no PAT (OR = 5.3, 95% CI = 2.2-12.7, p< 0.001) and longer duration of surgery than the mean time (68 min) (OR = 2.8, 95% CI = 1.2-6.6, p = 0.02) were identified as independent risk factors for SSI. Numbers needed to have PAT to avoid one SSI was 43.

CONCLUSIONS

In summary, this study clearly lends support to the use of PAT in surgery for lumbar disc herniation. Senior surgeons assisting inexperienced colleagues to avoid prolonged duration of surgery could also reduce the occurrence of SSI.

Vaccine development to prevent Staphylococcus aureus surgical-site infections

BACKGROUND

Staphylococcus aureus surgical-site infections (SSIs) are a major cause of poor health outcomes, including mortality, across surgical specialties. Despite current advances as a result of preventive interventions, the disease burden of S. aureus SSI remains high, and increasing antibiotic resistance continues to be a concern. Prophylactic S. aureus vaccines may represent an opportunity to prevent SSI.

METHODS

A review of SSI pathophysiology was undertaken in the context of evaluating new approaches to developing a prophylactic vaccine to prevent S. aureus SSI.

RESULTS

A prophylactic vaccine ideally would provide protective immunity at the time of the surgical incision to prevent initiation and progression of infection. Although the pathogenicity of S. aureus is attributed to many virulence factors, previous attempts to develop S. aureus vaccines targeted only a single virulence mechanism. The field has now moved towards multiple-antigen vaccine strategies, and promising results have been observed in early-phase clinical studies that supported the recent initiation of an efficacy trial to prevent SSI.

CONCLUSION

There is an unmet medical need for novel S. aureus SSI prevention measures. Advances in understanding of S. aureus SSI pathophysiology could lead to the development of effective and safe prophylactic multiple-antigen vaccines to prevent S. aureus SSI.

Comparing the Postoperative Complications, Hospitalization Days and Treatment Expenses Depending on the Administration of Postoperative Prophylactic Antibiotics to Hysterectomy

PURPOSE

This study was conducted to compare postoperative complications, hospitalization days and treatment expenses to postoperative prophylactic antibiotics administrated to hysterectomy or not.

METHODS

A retrospective survey study was performed with 128 cases in which elective hysterectomy had undergone. They were divided into two groups by identifying whether postoperative prophylactic antibiotics was administered for hysterectomy: a) one group who received postoperative prophylactic antibiotics and; b) those who did not. Data were collected using the electric medical record at a hospital and analyzed by SPSS 23.0 for χ2 test, t-test and ANCOVA.

RESULTS

Postoperative complications including wound infection (p=1.000), pneumonia (p=.496), hematoma (p=.530), and pneumoperitoneum (p=.496) showed no significant differences between two groups. Hospitalization days for the prophylactic antibioticsadministrated group were significantly longer than the non-administered for prophylactic antibiotics (p=.004). The treatment expenses of the prophylactic antibiotics-administrated group were significantly higher than those of the non-administered prophylactic antibiotics (F=4.31, p=.040).

CONCLUSION

These results can be provided for the evidence of administrating postoperative prophylactic antibiotics to hysterectomy. Additionally, it can contribute to decreasing the medication errors caused by infrequently administrating postoperative prophylactic antibiotics as well as to lessening likelihood of infection of intravenous injection site.

Postoperative comparison of the results from use of antibiotic prophylaxis for one and five days among patients undergoing lumbar arthrodesis

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.

Treatment of lumbar disc herniation with radiculopathy. Clinical practice guidelines endorsed by The Polish Society of Spinal Surgery

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.

American college of foot and ankle surgeons' clinical consensus statement: perioperative prophylactic antibiotic use in clean elective foot surgery

Some controversy exists regarding the use of antibiotic prophylaxis in elective foot and ankle surgery. A task force was appointed by the American College of Foot and Ankle Surgeons (ACFAS) to provide a clinical consensus statement on this topic. The panel members performed a literature search and identified 6 studies that met the inclusion criteria. They then developed a list of 13 questions about which they attempted to reach consensus using a modified Delphi method. The questions were grouped into 4 categories: indications for antibiotic prophylaxis relative to surgical procedure; antibiotic prophylaxis in high-risk patients; antibiotic selection; and timing of antibiotic prophylaxis. Consensus was reached for all 13 questions. The panel members found that studies pertaining specifically to elective foot and ankle surgeries that were not level I evidence generally did not recommend prophylaxis. They also found that multispecialty guidelines, which reflect data that are stronger, tended to recommend routine prophylaxis, especially for surgeries involving hardware. In addition, many hospital systems support routine prophylaxis by surgeons. More high-level evidence is required to make a definitive determination about whether prophylaxis is necessary in elective foot and ankle surgery. Until that time, routine prophylaxis will likely be continued at most institutions, because few complications have been reported with the practice.

Surgical site infections following spine surgery: eliminating the controversies in the diagnosis

Surgical site infection (SSI) following spine surgery is a dreaded complication with significant morbidity and economic burden. SSIs following spine surgery can be superficial, characterized by obvious wound drainage or deep-seated with a healed wound. Staphylococcus aureus remains the principal causal agent. There are certain pre-operative risk factors that increase the risk of SSI, mainly diabetes, smoking, steroids, and peri-operative transfusions. Additionally, intra-operative risk factors include surgical invasiveness, type of fusion, implant use, and traditional instead of minimally invasive approach. A high level of suspicion is crucial to attaining an early definitive diagnosis and initiating appropriate management. The most common presenting symptom is back pain, usually manifesting 2–4 weeks and up to 3 months after a spinal procedure. Scheduling a follow-up visit between weeks 2 and 4 after surgery is therefore necessary for early detection. Inflammatory markers are important diagnostic tools, and comparing pre-operative with post-operative levels should be done when suspecting SSIs following spine surgery. Particularly, serum amyloid A is a novel inflammatory marker that can expedite the diagnosis of SSIs. Magnetic resonance imaging remains the diagnostic modality of choice when suspecting a SSI following spine surgery. While 18F-fluorodeoxyglucose-positron emission tomography is not widely used, it may be useful in challenging cases. Despite their low yield, blood cultures should be collected before initiating antibiotic therapy. Samples from wound drainage should be sent for Gram stain and cultures. When there is a high clinical suspicion of SSI and in the absence of superficial wound drainage, computed tomography-guided aspiration of paraspinal collections is warranted. Unless the patient is hemodynamically compromised, antibiotics should be deferred until proper specimens for culture are secured.

Infection with spinal instrumentation: Review of pathogenesis, diagnosis, prevention, and management

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.

An evidence-based clinical guideline for antibiotic prophylaxis in spine surgery

BACKGROUND CONTEXT

The North American Spine Society's (NASS) Evidence-Based Clinical Guideline on Antibiotic Prophylaxis in Spine Surgery provides evidence-based recommendations to address key clinical questions regarding the efficacy and the appropriate antibiotic prophylaxis protocol to prevent surgical site infections in patients undergoing spine surgery. The guideline is intended to address these questions based on the highest quality clinical literature available on this subject as of June 2011.

PURPOSE

Provide an evidence-based educational tool to assist spine surgeons in preventing surgical site infections.

STUDY DESIGN

Systematic review and evidence-based clinical guideline.

METHODS

This guideline is a product of the Antibiotic Prophylaxis in Spine Surgery Work Group of NASS Evidence-Based Guideline Development Committee. The work group consisted of neurosurgeons and orthopedic surgeons who specialize in spine surgery and are trained in the principles of evidence-based analysis. A literature search addressing each question and using a specific search protocol was performed on English language references found in MEDLINE (PubMed), ACP Journal Club, Cochrane Database of Systematic Reviews Database of Abstracts of Reviews of Effectiveness, Cochrane Central Register of Controlled Trials, EMBASE (Drugs and Pharmacology), and Web of Science to identify articles published since the search performed for the original guideline. The relevant literature was then independently rated using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final recommendations to answer each clinical question were developed via work group discussion, and grades were assigned to the recommendations using standardized grades of recommendation. In the absence of Levels I to IV evidence, work group consensus statements have been developed using a modified nominal group technique, and these statements are clearly identified as such in the guideline.

RESULTS

Sixteen clinical questions were formulated and addressed, and the answers are summarized in this article. The respective recommendations were graded by the strength of the supporting literature, which was stratified by levels of evidence.

CONCLUSIONS

The clinical guideline for antibiotic prophylaxis in spine surgery has been created using the techniques of evidence-based medicine and best available evidence to aid practitioners in the care of patients undergoing spine surgery. The entire guideline document, including the evidentiary tables, suggestions for future research, and all the references, is available electronically on the NASS Web site at http://www.spine.org/Pages/PracticePolicy/ClinicalCare/ClinicalGuidlines/Default.aspx and will remain updated on a timely schedule.

A methodological systematic review on surgical site infections following spinal surgery: part 2: prophylactic treatments

STUDY DESIGN

A methodological systematic review.

OBJECTIVE

To critically appraise the validity of preventive effects attributed to prophylactic treatments for surgical site infection (SSI) after spinal surgery.

SUMMARY OF BACKGROUND DATA

As a result of a rapidly increasing number of spinal procedures, health care expenditure is expected to increase substantially in the foreseeable future. Administration of effective prophylactic treatments may prevent occurrence of SSIs and may thus result in lower costs. To date, however, no review appraising the methodological quality of studies evaluating prophylactic treatments for spinal SSIs has been published.

METHODS

Contemporary studies evaluating the preventive effect of prophylactic interventions on the rate of SSI after spinal surgery were searched through the Medline and EMBASE databases (January 2001 to December 2010). References were retrieved and bias-prone study features were abstracted individually and independently by 2 authors.

RESULTS

Eighteen eligible studies were identified, including 6 randomized controlled trials and 12 comparative cohort studies. Most often, antibiotic prophylaxis administration was investigated (n = 7). Included studies covered a wide variation of indications and surgical procedures. Except for 5 studies (28%), applied definitions of SSI outcomes were ambiguous. Although several important methodological aspects, including blinding of outcome assessors and attrition, were poorly reported in randomized controlled trials, these studies were far less susceptible to bias and confounding as observed in nonrandomized studies. None of the 12 cohort studies adjusted for confounding by matching, stratification, or multivariate regression techniques.

CONCLUSION

Given the plethora of previously hypothesized confounding risk factors for a spinal SSI, conduct of nonrandomized comparative therapeutic studies is strongly discouraged. On the other hand, methodological safeguards, including use of standardized definitions of putative confounders and outcomes, should be considered in more detail during the design phase of a randomized trial.

Infections in the operated spine: update on risk management and therapeutic strategies

Among the possible risks of spine surgery, surgical site infection (SSI) is far from negligible. Incidence is higher than in other locomotor system procedures, with more severe local and general impact. Certain broad guidelines can be formulated. The risk of SSI should be taken into account in the choice of treatment options discussed with the patient. Antibiotic prophylaxis, surgical prevention of iatrogenic infection and an SSI surveillance protocol should be implemented. SSI should be suspected in case of any abnormality in postoperative course, and biological and imaging (MRI or CT) measures should be taken. Local sampling for bacteriological identification is mandatory. Treatment strategy should ideally be discussed in a multidisciplinary coordination meeting, and adapted in the light of local bacterial ecology and resistance data. The information provided to the patient should be transparent and adapted to the patient's individual context.

LEVEL OF EVIDENCE

Level V.

Postoperative antimicrobial prophylaxis following spinal decompression surgery: is it necessary?

BACKGROUND

Antimicrobial prophylaxis (AMP) can reduce the risk of surgical-site infection (SSI) following many types of surgery, particularly spinal surgery. After publication of the Guideline for Prevention of Surgical Site Infection by the Centers for Disease Control and Prevention in 1999, a large number of studies confirmed the effectiveness of AMP. However, because the concept of AMP is not clear in Japan, the duration of postoperative AMP tends to be long. The purpose of this study was to compare the infection rates following spinal surgery for postoperative AMP versus no postoperative AMP.

METHODS

The study comprised 284 patients who underwent spinal surgery without instrumentation at our hospital from October 2003 to August 2009. The patients were divided into two groups based on the method of AMP administration: a postoperative dose group and a no postoperative dose group. SSI incidences were calculated for the two groups.

RESULTS

The incidence of SSI was 2.1% (6/284) overall and 2. 8% (4/141) vs. 1.4% (2/143) for the postoperative dose and no postoperative dose groups, respectively. The infection rate difference between the two groups was not significant. The incidence of SSI showed a downward trend as the frequency of antibiotics decreased. Two cases of pseudomembranous colitis, both in the postoperative dose group, were the only complications of the antibiotics.

CONCLUSIONS

AMP duration was not related to the SSI rate. SSIs trended lower in the no postoperative dose group compared with the postoperative dose group. Postoperative administration of AMP appears to be unnecessary for spinal decompression surgery without instrumentation.

Surgical site infection rates after minimally invasive spinal surgery

OBJECT

Postoperative surgical site infections (SSIs) have been reported after 2-6% of spinal surgeries in most large series. The incidence of SSI can be < 1% after decompressive procedures and > 10% after instrumented fusions. Anecdotal evidence has suggested that there is a lower rate of SSI when minimally invasive techniques are used.

METHODS

A retrospective review of prospectively collected databases of consecutive patients who underwent minimally invasive spinal surgery was performed. Minimally invasive spinal surgery was defined as any spinal procedure performed through a tubular retractor system. All surgeries were performed under standard sterile conditions with preoperative antibiotic prophylaxis. The databases were reviewed for any infectious complications. Cases of SSI were identified and reviewed for clinically relevant details. The incidence of postoperative SSIs was then calculated for the entire cohort as well as for subgroups based on the type of procedure performed, and then compared with an analogous series selected from an extensive literature review.

RESULTS

The authors performed 1338 minimally invasive spinal surgeries in 1274 patients of average age 55.5 years. The primary diagnosis was degenerative in nature in 93% of cases. A single minimally invasive spinal surgery procedure was undertaken in 1213 patients, 2 procedures in 58, and 3 procedures in 3 patients. The region of surgery was lumbar in 85%, cervical in 12%, and thoracic in 3%. Simple decompressive procedures comprised 78%, instrumented arthrodeses 20%, and minimally invasive intradural procedures 2% of the collected cases. Three postoperative SSIs were detected, 2 were superficial and 1 deep. The procedural rate of SSI for simple decompression was 0.10%, and for minimally invasive fusion/fixation was 0.74%. The total SSI rate for the entire group was only 0.22%.

CONCLUSIONS

Minimally invasive spinal surgery techniques may reduce postoperative wound infections as much as 10-fold compared with other large, modern series of open spinal surgery published in the literature.

Antibiotic prophylaxis in spine surgery: an evidence-based clinical guideline for the use of prophylactic antibiotics in spine surgery

BACKGROUND CONTEXT

The objective of the North American Spine Society's (NASS) Evidence-Based Clinical Guideline on Antibiotic Prophylaxis in Spine Surgery is to provide evidence-based recommendations on key clinical questions concerning the use of prophylactic antibiotics in spine surgery. The guideline is intended to address these questions based on the highest quality clinical literature available on this subject as of December 2006. The goal of the guideline recommendations is to assist in delivering optimum, efficacious treatment to prevent surgical site infection.

PURPOSE

To provide an evidence-based, educational tool to assist spine surgeons in preventing surgical site infections.

STUDY DESIGN

Evidence-based Clinical Guideline.

METHODS

This report is from the Antibiotic Prophylaxis Work Group of the NASS's Evidence-Based Clinical Guideline Development Committee. The work group comprised multidisciplinary surgical spine care specialists, who were trained in the principles of evidence-based analysis. Each member of the group formatted a series of clinical questions to be addressed by the group. The final questions agreed upon by the group are the subjects of this report. A literature search addressing each question and using a specific search protocol was performed on English language references found in MEDLINE, EMBASE (Drugs and Pharmacology), and four additional, evidence-based, databases. The relevant literature was then independently rated by at least three reviewers using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final grades of recommendation for the answer to each clinical question were arrived at via Webcast meetings among members of the work group using standardized grades of recommendation. When Level I to Level IV evidence was insufficient to support a recommendation to answer a specific clinical question, expert consensus was arrived at by the work group through the modified nominal group technique and is clearly identified in the guideline.

RESULTS

Eleven clinical questions addressed the efficacy and appropriateness of antibiotic prophylaxis protocols, repeat dosing, discontinuation, wound drains, and special considerations related to the potential impact of comorbidities on antibiotic prophylaxis. The responses to these 11 clinical questions are summarized in this document. The respective recommendations were graded by the strength of the supported literature which was stratified by levels of evidence.

CONCLUSIONS

A clinical guideline addressing the use of antibiotic prophylaxis in spine surgery has been created using the techniques of evidence-based medicine and the best available evidence. This educational tool will assist spine surgeons in preventing surgical site infections. The entire guideline document, including the evidentiary tables, suggestions for future research, and references, is available electronically at the NASS Web site (www.spine.org) and will remain updated on a timely schedule.

Long-term intravenous administration of antibiotics for lumbar spinal surgery prolongs the duration of hospital stay and time to normalize body temperature after surgery

STUDY DESIGN

Comparative study of differing durations of antibiotics for spinal surgery.

OBJECTIVE

To compare rate of infection, duration of hospital stay, days until normal body temperature, and a panel of blood tests after surgery between long-term and short-term administration of antibiotics for spinal surgery using instrumentation.

SUMMARY OF BACKGROUND DATA

Recent studies have reported that long-term administration of intravenous antibiotics is not necessary to avoid superficial and deep infections. We therefore changed the duration of administration from 9 to 2 days in our lumbar surgery patients.

METHODS

We examined 135 patients (average age, 64.9 years) who underwent lumbar spinal surgery to insert a pedicle screw system to treat spinal canal stenosis. We administered 2 g of cefotiam daily to 60 patients for 9 days after surgery and to 75 patients for 2 days after surgery. Surgical time, loss of blood, rate of infection, duration of hospital stay, days until normal body temperature, and data from blood analysis (white blood cell count, and C-reactive protein [CRP] level) were statistically compared between the 2 groups.

RESULTS

No significant differences in intraoperative measures of surgical invasion were observed between the 2 groups (surgical time, 209 vs. 220 minutes; blood loss, 530 vs. 576 mL; blood transfusion, 344 vs. 380 mL for the long-term and short-term groups, respectively). No acute infections occurred in either group. However, the duration of hospital stay (20.7 days), time until normal body temperature (5.1 days), and CRP level (2.23 mg/dL) at day 7 after surgery were significantly less in the short-term group than those in the long-term group (27.9 days, 6.8 days, and 3.13 mg/dL, respectively; P < 0.05).

DISCUSSION

These results indicate that short-term intravenous administration of antibiotics did not elevate the infection rate after spinal surgery using instrumentation. However, long-term administration of antibiotics prolonged the duration of hospital stay, inhibited normalization of body temperature, and elevated CRP levels. Long-term administration of antibiotics may suppress normal, beneficial bacteria, thereby having an adverse effect on patient recovery.

Effective prevention of surgical site infection using a Centers for Disease Control and Prevention guideline-based antimicrobial prophylaxis in lumbar spine surgery

OBJECT

Antimicrobial prophylaxis (AMP) reduces the rate of surgical site infection (SSI) in lumbar spine surgery, but a great deal of variation exists regarding the timing and duration of AMP. The authors had previously used prophylactic antibiotics for 5 to 7 postoperative days. Based on the Centers for Disease Control and Prevention (CDC) guideline, the AMP period was changed to the day of surgery only. In the current study, the authors compared the rate of SSI in lumbar spine surgeries between two different protocols of AMP.

METHODS

Data from 1597 consecutive uninfected patients who had undergone lumbar spine surgery between January 1999 and September 2004 were reviewed. The pathophysiologies among these patients included disc herniation in 686, degenerative spondylolisthesis in 340, spinal stenosis in 259, failed lumbar surgeries in 73, degenerative scoliosis in 52, isthmic spondylolisthesis in 48, spinal trauma in 34, foraminal stenosis in 27, spinal tumor in 27, and miscellaneous in 51 patients. The rate of SSI was compared between the two AMP groups. There were 1133 patients in the multiple-dose group, and 464 patients in the single-dose group. The rate of instrumentation surgery was not statistically different between the multiple-dose group (43%) and the single-dose group (39%). The overall rate of SSI was 0.7%. The SSI rate was 0.8% in the multiple-dose group and 0.4% in the single-dose group; the difference between the two was not significant. Regarding the organisms of SSI, resistant strains of bacteria were cultured in five (83.3%) of six patients in the multiple-dose group, whereas none was cultured in the single-dose group.

CONCLUSIONS

Data in the current study did not demonstrate a difference in the rate of SSI between the two different AMP protocols. Based on the CDC guideline, a single dose of AMP was proven to be efficacious for the prevention of SSI in lumbar spine surgeries. A shorter duration of first-generation cephalosporin use may effectively prevent the emergence of antibiotic-resistant bacterial infection.