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Tavanaei R, Ashghani MN, Ahmadi P, Alizadeh S, Yazdani KO, Zali A, Oraee-Yazdani S. Effects of Preoperative Use of Povidone-Iodine-Impregnated Dressing on Postoperative Rate of Surgical Site Infection in Patients Undergoing Posterolateral Lumbar Spinal Fusion Surgery: A Randomized, Nonblinded, Active-Controlled Trial. Neurosurgery 2023:00006123-990000000-00962. [PMID: 37971223 DOI: 10.1227/neu.0000000000002768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/02/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND AND OBJECTIVES No study has evaluated the efficacy of using preoperative antiseptic dressings in reducing the rate of surgical site infection (SSI) in spine surgery thus far. To investigate the efficacy of the use of preoperative povidone-iodine-impregnated antiseptic dressings in patients undergoing instrumented posterolateral lumbar spinal fusion. METHODS This was a randomized, nonblinded, active-controlled, parallel-group clinical trial. Patients were randomly assigned to the 2 study groups, including treatment and control. Patients in the treatment group received povidone-iodine-impregnated antiseptic dressing applied to the anticipated incision site 12 hours before the operation. The control group merely received the standard perioperative care with no additional intervention or placebo. Patients were followed up for 90 days, and SSIs were recorded. RESULTS A total of 200 patients were included in this study (100 in each arm). Three cases of SSI were observed in the treatment group compared with 12 in the control one. A significant reduction in the postoperative rate of SSI was observed in the treatment group compared with the control one (P = .029). In addition to study intervention (P = .029), body mass index (P = .005), smoking status (P = .005), duration of the procedure (P = .003), American Society of Anesthesiologists class (P = .002), and diabetes mellitus (P < .001) were significantly associated with the postoperative rate of SSI. CONCLUSION To the best of our knowledge, this study for the first time showed that preoperative use of antiseptic dressings is significantly effective in reducing the rate of SSI in instrumented posterior lumbar spinal fusion surgery. Future studies are warranted to evaluate the efficacy of different preparations or the effectiveness of the present one in patients undergoing spine procedures with other surgical characteristics.
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Affiliation(s)
- Roozbeh Tavanaei
- Department of Neurosurgery, Functional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Nasirzadeh Ashghani
- Department of Neurosurgery, Functional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Pooria Ahmadi
- Department of Neurosurgery, Functional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sajjad Alizadeh
- Department of Neurosurgery, Functional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Kaveh Oraii Yazdani
- Department of Cardiovascular Diseases, Zahedan University of Medical Science, Zahedan, Iran
| | - Alireza Zali
- Department of Neurosurgery, Functional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Saeed Oraee-Yazdani
- Department of Neurosurgery, Functional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Parlak EA, Iyigun E, Albay A, Bedir O. Impact of methods and duration of surgical hand scrub on bacterial count: A randomized controlled trial. Am J Infect Control 2021; 49:1376-1383. [PMID: 34029650 DOI: 10.1016/j.ajic.2021.05.006] [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: 03/11/2021] [Revised: 05/12/2021] [Accepted: 05/15/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND There is no standard protocol for surgical scrubbing. This study aims to compare the effectiveness of surgical hand scrub duration and method by analyzing their effects on bacterial count. METHODS The study was conducted on 180 surgical nurses and surgeons. While the duration of surgical hand scrub in Groups I and II was one minute, participants in Group I used a nail brush, whereas Group II did not. Similarly, the duration of surgical hand scrub in Groups III and IV was two minutes, but Group III used a nail brush, whereas Group IV did not. Bacterial count on the hands of all participants was measured before and after the surgical hand scrub and after the surgery by using the glove juice method. RESULTS Bacterial count on the hands of the participants in Group III after surgical hand scrub was significantly higher than Group IV (P < .001). We did not find any statistically significant difference between Group II and Group IV in terms of bacterial count on the hands immediately after surgical hand scrub and after the surgery (P = .401, P =.658, respectively). CONCLUSIONS This study found that brushing during surgical hand scrub increased the number of bacteria on the hand. Besides, one-minute surgical hand scrub was equally effective as two-minute scrub to reduce the number of bacteria on the hand.
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Mastrocola M, Matziolis G, Böhle S, Lindemann C, Schlattmann P, Eijer H. Meta-analysis of the efficacy of preoperative skin preparation with alcoholic chlorhexidine compared to povidone iodine in orthopedic surgery. Sci Rep 2021; 11:18634. [PMID: 34545135 PMCID: PMC8452611 DOI: 10.1038/s41598-021-97838-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 08/25/2021] [Indexed: 01/02/2023] Open
Abstract
Preoperative skin preparation is an effective method to prevent surgical site infections (SSI). Alcoholic chlorhexidine (CHG) and povidone iodine (PV-I) are the most widely used antiseptic agents. This meta-analysis aims to determine their efficacy in reducing natural bacterial skin flora in clean orthopedic surgery. A systematic search was conducted through current literature up to June 2021 to identify clinical randomized trials that compared the efficacy of alcoholic chlorhexidine and povidone iodine in reducing bacterial skin colonization after preoperative skin preparation. A meta-analysis was conducted. Of 235 screened articles, 8 randomized controlled trials were included. The results of the meta-analysis demonstrate a significantly lower positive culture rate in the chlorhexidine group than in the povidone iodine group (RR = 0.53, 95% Cl: 0.32-0.88). The present data show the superiority of chlorhexidine in reducing the normal bacterial flora compared to povidone iodine in clean orthopedic surgery.
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Affiliation(s)
- Mario Mastrocola
- Department of Orthopaedic Surgery, Spital Emmental, Oberburgstrasse 54, 3400, Burgdorf, Switzerland
| | - Georg Matziolis
- Orthopaedic Department, Campus Eisenberg, Jena University Hospital, Klosterlausnitzer Str. 81, 07607, Eisenberg, Germany.
| | - Sabrina Böhle
- Orthopaedic Department, Campus Eisenberg, Jena University Hospital, Klosterlausnitzer Str. 81, 07607, Eisenberg, Germany
| | - Chris Lindemann
- Orthopaedic Department, Campus Eisenberg, Jena University Hospital, Klosterlausnitzer Str. 81, 07607, Eisenberg, Germany
| | - Peter Schlattmann
- Department of Medical Statistics, Computer Sciences and Documentation, Jena University Hospital, Bachstr. 18, 07743, Jena, Germany
| | - Henk Eijer
- Department of Orthopaedic Surgery, Spital Emmental, Oberburgstrasse 54, 3400, Burgdorf, Switzerland
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Sawires AN, Park PJ, Lenke LG. A narrative review of infection prevention techniques in adult and pediatric spinal deformity surgery. JOURNAL OF SPINE SURGERY (HONG KONG) 2021; 7:413-421. [PMID: 34734145 PMCID: PMC8511566 DOI: 10.21037/jss-21-10] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 05/20/2021] [Indexed: 06/13/2023]
Abstract
Spinal infections associated with pediatric and adult spinal deformity surgery are associated with postoperative morbidity and mortality along with elevated health-care costs. Prevention requires meticulous technique by the spine surgeon throughout the perioperative period. There is significant variability in the current practices of spinal deformity surgeons with regard to infection prevention, stemming from the lack of reliable evidence available in the literature. There has also been a lack of literature detailing the difference in infection rates and risk factors between pediatric and adult patients undergoing deformity correction surgery. In this narrative review we looked at 60 studies in the adult population and 9 studies in the pediatric population. Most of these studies of surgical site infections (SSI) in spinal deformity surgery have been performed in adult patients, however it is clear that the pediatric neuromuscular patient requires particular attention that we discuss in detail. This narrative review of the literature outlines evidence and compares and contrasts data for preventive strategies and modifiable risk factors to decrease rates of SSI in the pediatric and adult spinal deformity patient populations. In this review we discuss techniques relating to preoperative cleansing protocols, antibiotic administration, gentle soft tissue handling, appropriate closure, drain usage, and intraoperative technique itself to minimize EBL and operative time.
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Affiliation(s)
- Andrew N. Sawires
- Lenox Hill Hospital, Department of Orthopaedic Surgery, New York, NY, USA
| | - Paul J. Park
- Columbia University Irving Medical Center, Department of Orthopedic Surgery, New York, NY, USA
| | - Lawrence G. Lenke
- Columbia University Irving Medical Center, Department of Orthopedic Surgery, New York, NY, USA
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5
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Dockery DM, Allu S, Vishwanath N, Li T, Berns E, Glasser J, Spake CSL, Antoci V, Born CT, Garcia DR. Review of Pre-Operative Skin Preparation Options Based on Surgical Site in Orthopedic Surgery. Surg Infect (Larchmt) 2021; 22:1004-1013. [PMID: 34388024 DOI: 10.1089/sur.2021.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Surgical site infections (SSIs) are a primary contributor to surgical morbidity and mortality, causing a substantial financial burden on the healthcare system. Specifically, Cutibacterium acnes contributes greatly to infections in the shoulder and spine regions. Prevention of infection is crucial to improve patient outcomes and reduce costs. This article reviews current surgical skin preparation solutions, the unique distribution of organisms at common orthopedic surgical sites, and recommends solutions based on surgical location. Methods: A search of electronic databases (PubMed, MEDLINE, and Embase) was conducted for relevant literature until December 2020. Sources were compiled based on title and abstract, then full texts were read for possible inclusion. This review summarizes the most recent publications in the field of SSIs and preparation solutions. Results: The mechanism and efficacy of alcohol-, iodine-, and chlorhexidine-based preparations were reviewed, along with experimental preparations. This article identifies common colonization patterns for the shoulder, elbow, hip, knee, spine, foot, and ankle, and discusses recommendations for preparations based on current evidence. Recommendations: For shoulder and elbow operations, we recommend ChloraPrep™ (CareFusion, BD, El Paso, TX), DuraPrep™ (3M Health Care, St. Paul, MN), or Betadine® applied with 4 × 4 gauze sponge, three-day pre-operative benzyl peroxide, and application of 3% hydrogen peroxide before skin preparation. For the hip and knee, we recommend application of 2% chlorhexidine gluconate (CHG) cloth the night before and morning of surgery and either DuraPrep or iodine-alcohol skin prep prior to surgery. For spine surgeries, we recommended ChloraPrep. For foot and ankle, our recommendations are: ChloraPrep or DuraPrep, submersion of foot in 70% ethanol/10% isopropyl alcohol for five minutes prior to procedure, application with a bristled brush, and a second vigorous scrub with 4 × 4 soaked gauze. Conclusions: The current surgical skin preparations have both benefits and drawbacks. We recommend that orthopedic surgeons choose a skin preparation based on surgical site and prevalence of unique skin flora there.
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Affiliation(s)
- Dominique M Dockery
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Sai Allu
- Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA
| | - Neel Vishwanath
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Troy Li
- Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA
| | - Ellis Berns
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Jillian Glasser
- Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Carole S L Spake
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Valentin Antoci
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA.,Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Christopher T Born
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA.,Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Dioscaris R Garcia
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA.,Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, 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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The Comparative Efficacy of Chlorhexidine Gluconate and Povidone-iodine Antiseptics for the Prevention of Infection in Clean Surgery: A Systematic Review and Network Meta-analysis. Ann Surg 2020; 274:e481-e488. [PMID: 32773627 DOI: 10.1097/sla.0000000000004076] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE There is uncertainty around preoperative skin antisepsis in clean surgery. Network meta-analysis provides more precise estimates than standard pairwise meta-analysis and can rank interventions by efficacy, to better inform clinical decisions. BACKGROUND Infection is the most common and costly complication of surgery. The relative efficacy of CHG and PVI based skin antiseptics in clean surgery remains unclear. METHODS We searched for randomized or nonrandomized studies comparing the effect of different preparations of CHG and PVI on the dichotomous outcome of surgical site infection. We included studies of adults undergoing clean surgery. We excluded studies concerning indwelling vascular catheters, blood sampling, combination antiseptics or sequential applications of different antiseptics. We performed a network meta-analysis to estimate the relative efficacy of interventions using relative risks (RR). RESULTS We included 17 studies comparing 5 antiseptics in 14,593 individuals. The overall rate of surgical site infection was 3%. Alcoholic CHG 4%-5% was ranked as the most effective antiseptic as it halved the risk of surgical site infection when compared to aqueous PVI [RR 0.49 (95% confidence interval 0.24, 1.02)] and also to alcoholic PVI, although uncertainty was larger [RR 0.51 (95% confidence interval 0.21, 1.27)]. Adverse events related to antiseptic application were only observed with patients exposed to PVI. CONCLUSIONS Alcoholic formulations of 4%-5% CHG seem to be safe and twice as effective as PVI (alcoholic or aqueous solutions) in preventing infection after clean surgery in adults. Our findings concur with the literature on contaminated and clean-contaminated surgery, and endorse guidelines worldwide which advocate the use of alcoholic CHG for preoperative skin antisepsis. REGISTRATION PROSPERO ID CRD42018113001.
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To The Editor. Spine (Phila Pa 1976) 2020; 45:E415-E416. [PMID: 32168139 DOI: 10.1097/brs.0000000000003391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Ramhmdani S, Bydon A. Commentary: Chlorhexidine Showers are Associated With a Reduction in Surgical Site Infection Following Spine Surgery: An Analysis of 4266 Consecutive Surgeries. Neurosurgery 2019; 85:E1006-E1007. [PMID: 30759256 DOI: 10.1093/neuros/nyy595] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 11/09/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- Seba Ramhmdani
- The Spinal Column Biomechanics and Surgical Outcomes Laboratory, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ali Bydon
- The Spinal Column Biomechanics and Surgical Outcomes Laboratory, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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