The Utility of Prolonged Prophylactic Systemic Antibiotics (PPSA) for Subfascial Drains After Degenerative Spine Surgery

The utility of surgical drains in adult and pediatric posterior spinal fusion: systematic review and meta-analysis

Surgical drains are utilized in spinal surgery to reduce the incidence of epidural hematomas (EDHs) and to facilitate optimal wound healing. Despite their widespread use, there is a paucity of data to support their utility. The goal of this systematic review and meta-analysis is to compare the effect of using drains versus no drains on postoperative outcomes in adult and pediatric patients undergoing posterior spinal fusions for deformity or degenerative conditions. The following outcomes were assessed: SSIs, EDHs, reoperations, transfusions, and length of stay (LOS). A systematic review of the literature in databases was conducted for all relevant literature. Exclusion criteria included single level decompressions, minimally invasive fusions, anterior-only approaches, and any surgical procedures performed for tumor, trauma, and osteomyelitis. Forest plots for Odds Ratios (ORs) and Mean Differences (MDs) were generated using random effects model. The search identified 2,210 titles, of which 11 studies were chosen for final analysis. 5 studies involved pediatric patients, while 6 included adult patients. A total of 3293 patients were analyzed-2,060 had a drain, and 1,233 had no drain. There were no statistically significant differences in the ORs of SSIs, EDHs, reoperations, and transfusions. LOS in adults was higher in the Drain group (MD 1.36 days 95% CI 0.25 - 2.47). This meta-analysis found no benefit in surgical drains in posterior spinal fusion in reducing the incidence of SSI, EDH, and reoperation. Drains may be associated with longer LOS in the adult population. PROSPERO registration number: CRD42023417315.

Extended Postoperative Antibiotic Prophylaxis Is Associated with No Clinical Value and Higher Projected Cost Following Adult Spinal Surgery: A Stratified Meta-Analysis and Probability-Based Cost Projections

» We aimed to determine the cost-effectiveness of different protocols of extended postoperative antibiotic prophylaxis (E-PAP) following adult spinal surgery.

» Both stratified (randomized controlled trials only) and nonstratified (all studies) analyses demonstrated that E-PAP has no significant value in reducing the rate of surgical site infection (SSI), deep SSI, or superficial SSI.

» Notably, the E-PAP protocols were associated with a significant increase in the length of hospital stay, resulting in an additional expenditure of $244.4 per episode for the E-PAP 72 hours protocol compared with PAP 24 hours and $309.8 per episode for the E-PAP >48 hours protocol compared with PAP <48 hours.

» E-PAP does not demonstrate any significant reduction in the rate of SSIs following spine surgery. However, these extended protocols were significantly associated with an increase in the length of hospital stay and higher overall projected costs.

Post-operative antibiotic prophylaxis in spine surgery patients with thoracolumbar drains: A meta analysis

Objective

Closed-suction drains are commonly placed after thoracolumbar surgery to reduce the risk of post-operative hematoma and neurologic deterioration, and may stay in place for a longer period of time if output remains high. Prolonged maintenance of surgical site drains, however, is associated with an increased risk of surgical site infection (SSI). The present study aims to examine the literature regarding extended duration (≥24 h) prophylactic antibiotic use in patients undergoing posterior thoracolumbar surgery with closed-suction drainage.

Methods

This systematic review was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Relevant studies reporting the use of 24-h post-operative antibiotics compared with extended duration post-operative antibiotics in patients undergoing posterior thoracolumbar surgery with closed-suction drainage were identified from a PubMed database query.

Results

Six studies were included for statistical analysis, encompassing 1003 patients that received 24 h of post-operative antibiotics and 984 patients that received ≥24 h of post-operative antibiotics. The SSI rate was 5.16 % for the shorter duration group (24 h) and 4.44 % (p = 0.7865) for the longer duration group (≥24 h).

Conclusions

There is no significant difference in rates of SSI in patients receiving 24 h of post-operative antibiotics compared with patients receiving ≥24 h of post-operative antibiotics. Shorter durations of post-operative antibiotics in patients with thoracolumbar drains have similar outcomes compared to patients receiving longer courses of antibiotics. Shorter durations of antibiotics could potentially help lead to lower overall cost and length of stay for these patients.

Association between duration of antimicrobial prophylaxis and postoperative outcomes after lumbar spine surgery

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.

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.

Lack of association of post-discharge prophylactic antibiotics with decreased risk of surgical site infection following spinal fusion

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.