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

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.

The Neurostimulation Appropriateness Consensus Committee (NACC)®: Recommendations for the Mitigation of Complications of Neurostimulation

INTRODUCTION

The International Neuromodulation Society convened a multispecialty group of physicians based on expertise and international representation to establish evidence-based guidance on the mitigation of neuromodulation complications. This Neurostimulation Appropriateness Consensus Committee (NACC)® project intends to update evidence-based guidance and offer expert opinion that will improve efficacy and safety.

MATERIALS AND METHODS

Authors were chosen on the basis of their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches of MEDLINE, BioMed Central, Current Contents Connect, Embase, International Pharmaceutical Abstracts, Web of Science, Google Scholar, and PubMed from 2017 (when NACC last published guidelines) to October 2023. Identified studies were graded using the United States Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations are based on the strength of evidence or consensus when evidence was scant.

RESULTS

The NACC examined the published literature and established evidence- and consensus-based recommendations to guide best practices. Additional guidance will occur as new evidence is developed in future iterations of this process.

CONCLUSIONS

The NACC recommends best practices regarding the mitigation of complications associated with neurostimulation to improve safety and efficacy. The evidence- and consensus-based recommendations should be used as a guide to assist decision-making when clinically appropriate.

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.

The Neurostimulation Appropriateness Consensus Committee (NACC): Recommendations for Surgical Technique for Spinal Cord Stimulation

INTRODUCTION

The field of neurostimulation for the treatment of chronic pain is a rapidly developing area of medicine. Although neurostimulation therapies have advanced significantly as a result of technologic improvements, surgical planning, device placement, and postoperative care are of equal importance to optimize outcomes. This Neurostimulation Appropriateness Consensus Committee (NACC) project intends to provide evidence-based guidance for these often-overlooked areas of neurostimulation practice.

MATERIALS AND METHODS

Authors were chosen based on their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches of MEDLINE, BioMed Central, Current Contents Connect, Embase, International Pharmaceutical Abstracts, Web of Science, Google Scholar, and PubMed from the last NACC publication in 2017 to the present. Identified studies were graded using the United States Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations are based on evidence strength and consensus when evidence was scant.

RESULTS

This NACC project provides guidance on preoperative assessment, intraoperative techniques, and postoperative management in the form of consensus points with supportive evidence. These results are based on grade of evidence, strength of consensus, and expert opinion.

CONCLUSIONS

The NACC has given guidance for a surgical plan that encompasses the patient journey from the planning stage through the surgical experience and postoperative care. The overall recommendations are designed to improve efficacy and the safety of patients undergoing these neuromodulation procedures and are intended to apply throughout the international community.

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.

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.

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

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.

Analysis of a ten step protocol to decrease postoperative spinal wound infections

AIM

To define a ten-step protocol that reduced the incidence of surgical site infection in the spine surgery practice of the senior author and evaluate the support for each step based on current literature.

METHODS

In response to unexplained increased infection rates at our institution following spine surgery, a ten-step protocol was implemented: (1) preoperative glycemic management based on hemoglobin A1c (HbA1c); (2) skin site preoperative preparation with 2% chlorhexidine gluconate disposable cloths; (3) limit operating room traffic; (4) cut the number of personnel in the room to the minimum required; (5) absolutely no flash sterilization of equipment; (6) double-gloving with frequent changing of outer gloves; (7) local application of vancomycin powder; (8) re-dosing antibiotic every 4 h for prolonged procedures and extending postoperative coverage to 72 h for high-risk patients; (9) irrigation of subcutaneous tissue with diluted povidone-iodine solution after deep fascial closure; and (10) use of DuraPrep skin preparation at the end of a case before skin closure. Through an extensive literature review, the current data available for each of the ten steps was evaluated.

RESULTS

Use of vancomycin powder in surgical wounds, routine irrigation of surgical site, and frequent changing of surgical gloves are strongly supported by the literature. Preoperative skin preparation with chlorhexidine wipes is similarly supported. The majority of current literature supports control of HbA1c preoperatively to reduce risk of infection. Limiting the use of flash sterilization is supported, but has not been evaluated in spine-specific surgery. Limiting OR traffic and number of personnel in the OR are supported although without level 1 evidence. Prolonged use of antibiotics postoperatively is not supported by the literature. Intraoperative use of DuraPrep prior to skin closure is not yet explored.

CONCLUSION

The ten-step protocol defined herein has significantly helped in decreasing surgical site infection rate. Several of the steps have already been shown in the literature to have significant effect on infection rates. As several measures are required to prevent infection, instituting a standard protocol for all the described steps appears beneficial.

The Neurostimulation Appropriateness Consensus Committee (NACC) Recommendations for Infection Prevention and Management

INTRODUCTION

The use of neurostimulation for pain has been an established therapy for many decades and is a major tool in the arsenal to treat neuropathic pain syndromes. Level I evidence has recently been presented to substantiate the therapy, but this is balanced against the risk of complications of an interventional technique.

METHODS

The Neurostimulation Appropriateness Consensus Committee (NACC) of the International Neuromodulation Society convened an international panel of well published and diverse physicians to examine the best practices for infection mitigation and management in patients undergoing neurostimulation. The NACC recommendations are based on evidence scoring and peer-reviewed literature. Where evidence is lacking the panel added expert opinion to establish recommendations.

RESULTS

The NACC has made recommendations to improve care by reducing infection and managing this complication when it occurs. These evidence-based recommendations should be considered best practices in the clinical implantation of neurostimulation devices.

CONCLUSION

Adhering to established standards can improve patient care and reduce the morbidity and mortality of infectious complications in patients receiving neurostimulation.

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.

The appropriate use of neurostimulation: avoidance and treatment of complications of neurostimulation therapies for the treatment of chronic pain. Neuromodulation Appropriateness Consensus Committee

INTRODUCTION

The International Neuromodulation Society (INS) has determined that there is a need for guidance regarding safety and risk reduction for implantable neurostimulation devices. The INS convened an international committee of experts in the field to explore the evidence and clinical experience regarding safety, risks, and steps to risk reduction to improve outcomes.

METHODS

The Neuromodulation Appropriateness Consensus Committee (NACC) reviewed the world literature in English by searching MEDLINE, PubMed, and Google Scholar to evaluate the evidence for ways to reduce risks of neurostimulation therapies. This evidence, obtained from the relevant literature, and clinical experience obtained from the convened consensus panel were used to make final recommendations on improving safety and reducing risks.

RESULTS

The NACC determined that the ability to reduce risk associated with the use of neurostimulation devices is a valuable goal and possible with best practice. The NACC has recommended several practice modifications that will lead to improved care. The NACC also sets out the minimum training standards necessary to become an implanting physician.

CONCLUSIONS

The NACC has identified the possibility of improving patient care and safety through practice modification. We recommend that all implanting physicians review this guidance and consider adapting their practice accordingly.

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.