Outcomes of an Intraoperative Povidone-Iodine Irrigation Protocol in Spinal Surgery for Surgical Site Infection Prevention

Risk Factors for Surgical Site Infections and the Effects of Betadine Irrigation and Intrawound Vancomycin Powder on Infection Rates in Spine Tumor Surgery

Background Surgical site infection (SSI) following spine tumor surgery results in delays in radiation therapy and the initiation of systemic treatment. The study aims to assess risk factors for SSI in malignancy-related spinal infections and rates of infection observed in a single center with the use of betadine irrigation (BI) and intrawound vancomycin powder (IVP).  Methods Spine tumor patients managed from 11/2012 to 11/2023 were identified using a surgical database (JotLogs, Efficient Surgical Apps, Portland, Maine). Inclusion criteria were patients receiving BI and IVP and alive at 30 days post-op. Exclusion criteria were patients not receiving a combination of BI and IVP due to allergies and mortality within 30 days of surgery. Patient demographics, histology, history of pre-operative and post-operative radiation treatment history, tumor location, procedure type, number of procedures per patient, SSI, wound culture results, and mortality were collected. Results One hundred two patients undergoing 130 procedures had an SSI rate of 3.85% (5/130). There were 18.6% primary and 81.4% metastatic tumors. Demographics were average age 59.5 years old (range 7-92), 60.8% male, 39.2% female, White 88.2%, Black 9.8%, and others 2%. Pre-operative radiation therapy was significantly associated with the risk of SSI (p=0.005). Percutaneous instrumentation did not lead to a significant difference in infection rates (p=0.139). There was no significant difference in infection rates between primary and metastatic tumors (p=0.58). Multivariable regression analysis revealed pre-operative radiation (OR: 18.1; 95%CI: 1.9-172.7; p=0.009) as the statistically significant independent risk factor. Conclusions Pre-operative radiation therapy remains a risk factor for SSI. However, percutaneous instrumentation did not lead to SSI, and there was no significant difference in infection rates between primary and metastatic tumors. SSI rate was 3.85% in patients who had a combination of BI and IVP in spine tumor surgery.

Relationship between 25-hydroxy Vitamin D level and surgical site infection in spine surgery

Background

25-hydroxy Vitamin D (25[OH]D) level has been shown to have antimicrobial and wound healing effects in animal models. Low preoperative 25(OH)D has been shown to correlate with surgical site infection (SSI) in thoracolumbar spine surgery.

Methods

This study involved 545 patients undergoing thoracolumbar spine surgery from 2012 to 2019 at an academic medical center. We evaluated the serum 25(OH)D level (i.e., adequate level = level 30-60 ng/dL), along with SSI, body mass index, and smoking status. Statistical analysis was done using bivariate analysis with Fisher's exact, Wilcoxon rank-sum test and multivarible logisitic regression analyses.

Results

We included 545 patients in the study, and there were no statistical differences in the average preoperative 25(OH)D between SSI and non-SSI groups. The average 25(OH)D in the non-SSI group was 31.6 ng/dL ± 13.6, and the SSI group was 35.7 ng/dL ± 20.2 (P = 0.63).

Conclusion

SSI rates following thoracolumbar spine surgery were not affected by preoperative 25(OH)D levels.

A meta-analysis examining the impact of intrawound treatment on reducing deep surgical site infections during instrumented spine surgery

The purpose of the meta-analysis was to evaluate and compare the effect of intrawound management on decreasing deep surgical site infections (SSIs) in instrumented spinal surgery (SS). The results of this meta-analysis were analysed, and the odds ratio (OR) and mean difference (MD) with 95% confidence intervals (CIs) were calculated using dichotomous or contentious random or fixed effect models. For the current meta-analysis, 29 examinations spanning from 2006 to 2022 were included, encompassing 11 181 people who had instrumented SS. Intrawound management had a significantly lower deep SSI when using vancomycin (OR, 0.34; 95% CI, 0.25-0.44, p < 0.001) and povidone-iodine as intrawound management (OR, 0.24; 95% CI, 0.13-0.42, p < 0.001) compared to control in instrumented SS subjects. The data that was looked at showed that using vancomycin and povidone-iodine as intrawound management had a much lower deep SSI than using a control group of instrumented SS subjects. However, given that some studies included a small number of subjects, attention should be given to their values.

Irrigation techniques used in spine surgery for surgical site infection prophylaxis: a systematic review and meta-analysis

Background

The greater likelihood of morbidity, mortality, length of hospital stays and poorer long-term outcomes as a result of surgical site infections secondary to spinal surgery makes prophylactic measures an imperative focus. Therefore, the aim of this review was to evaluate the available research related to the efficacy of different intraoperative irrigation techniques used in spinal surgery for surgical site infection (SSI) prophylaxis.

Methods

We performed a comprehensive search using Ovid Medline, EMBASE, Web of Science and the Cochrane library pertaining to this topic. Our meta-analysis was conducted according to PRISMA guidelines. The inclusion criteria consist of spine surgeries with intraoperative use of any wound irrigation technique, comparison groups with a different intraoperative irrigation technique or no irrigation, SSI identified with bacterial cultures or clinically in the postoperative period, reported SSI rates. Data extracted from eligible studies included, but was not limited to, SSI rates, irrigation technique and control technique. Exclusion criteria consist of articles with no human subjects, reviews, meta-analyses and case control studies and no details about SSI identification or rates. Pooled risk ratios were calculated. A meta-analysis was performed with a forest plot to determine risk estimates’ heterogeneity with I² index, Q-statistic, and p value under a random-effects model. Funnel plot was used to assess publication bias. All databases were last checked on January, 2022. PROBAST tool was used to assess both risk of bias and applicability concerns.

Results

After reviewing 1494 titles and abstracts, 18 articles met inclusion criteria. They included three prospective randomized-controlled trials, 13 retrospective cohort studies, two prospective cohort studies. There were 54 (1.8%) cases of SSIs in the povidone-iodine irrigation group (N = 2944) compared to 159 (4.6%) in the control group (N = 3408). Using intraoperative povidone-iodine wound irrigation produced an absolute risk reduction of 2.8%. Overall risk ratio was 0.32 (95% CI 0.20–0.53, p < 0.00001). In a global analysis, study heterogeneity and synthesizing mostly retrospective data were primary limitations.

Conclusion

The most evidence exists for povidone-iodine and has Level 2 evidence supporting SSI reduction during spinal surgery. Other antiseptic solutions such as dilute chlorhexidine lack published evidence in this patient population which limits the ability to draw conclusions related to its use in spinal surgery.

Level of Evidence

II – Systematic Review with Meta-Analysis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05763-2.

Wound Irrigation Using Wet Gauze May Reduce Surgical Site Infection Following Laparoscopic Appendectomy

Purpose

This study aimed to compare the perioperative outcomes of wet gauze and conventional irrigation after laparoscopic appendectomy to determine whether wet gauze irrigation can help reduce surgical site infection (SSI).

Methods

A total of 308 patients undergoing laparoscopic appendectomy were included in this study between December 2018 and May 2020. Of these, 132 (42.9%) received gauze irrigation (group 1), and 176 patients (57.1%) received conventional irrigation (group 2). Pre-operative outcomes and complications, including SSI, were compared after propensity score matching (PSM) to adjust for baseline differences and selection bias.

Results

After 1:1 PSM, 92 well-matched patients in each group were evaluated. Regarding perioperative outcomes between groups 1 and 2, the rate of severe complications (Clavien-Dindo Classification grades III, IV, and V), operative time, and readmission rate did not differ between the groups. Superficial/deep SSIs were observed more frequently in group 2 (8/92 cases) than in group 1 (1/92 cases; p = 0.017). The organ/space SSIs rate was not significantly different between the two groups (1/92 group 1 and 0/92 group 2, p = 0.316). However, post-operative hospital stay was significantly longer in group 2 (2.8 ± 1.3 days) than in group 1 (1.6 ± 1.2 days; p < 0.001). In the univariate analyses, wound irrigation using wet gauze was an independent protective factor for superficial or deep SSI (p = 0.044).

Conclusions

Wound irrigation using wet gauze after fascia closure has a significant beneficial effect on reducing post-operative superficial/deep SSI following laparoscopic appendectomy.

Surgical decompression timing for patients with foot drop from lumbar degenerative diseases: a meta-analysis

OBJECTIVE

To compare the outcomes of early (within 1 month after foot drop) decompression versus late (1 month or more after foot drop) decompression in order to determine the optimal surgical intervention timing for lumbar degenerative diseases.

METHODS

The MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science and SCOPUS electronic databases were searched for relevant articles published until May 2021 were conducted. Cochrane Collaboration guidelines were used for data extraction and quality assessment. Outcomes of interest were manual muscle testing (MMT) and recovery rate (MMT ≥ 4) for foot drop in lumbar degenerative diseases.

RESULTS

Six clinical studies were retrieved, including 312 randomized participants. One hundred fifty-seven patients underwent early decompression surgery, and 155 underwent late decompression surgery. There were significant differences between the two groups in recovery rate (95% confidence interval [CI] 1.59, 2.57) and neurological improvement (95% confidence interval [CI] 0.21, 1.66). Early surgical decompression provided better recovery rate and neurological improvement for foot drop in lumbar degenerative diseases than late surgical decompression.

CONCLUSION

Early surgical decompression within was beneficial in terms of recovery rate and neurological improvement compared with late surgery. Early surgical decompression (within 1 month) is recommended for patients with foot drop in lumbar degenerative diseases.

Local antibiotics in posterior lumbar fusion procedures for neuromuscular scoliosis: a case for their use

BACKGROUND CONTEXT

Surgical site infections (SSIs) are medically devastating and financially costly complications after posterior spinal fusion (PSF) for neuromuscular scoliosis (NMS). Many strategies exist to reduce their occurrence. The efficacy of intraoperative antibiotics in the wound or bone graft is gaining in popularity, but this practice has not been well-studied in the PSF NMS population.

PURPOSE

To assess the potential utility of intraoperative local antibiotics in patients with NMS undergoing PSF.

STUDY DESIGN/SETTING

Retrospective review of prospectively collected data.

PATIENT SAMPLE

Pediatric patients who underwent PSF for NMS were identified from the 2016-2018 National Surgical Quality Improvement Program (NSQIP) pediatric spinal fusion datasets.

OUTCOME MEASURES

Perioperative adverse outcome variables assed included the occurrence of SSI, renal complications, and adverse hospital metrics.

METHODS

Patient demographic factors, comorbidities, and the use of intraoperative antibiotics in the wound were recorded (a specifically assessed variable in the dataset). The association between the use of intraoperative antibiotics and the occurrence of adverse outcomes/infection was assessed for the entire study population and higher risk sub-populations.

RESULTS

In total, 1,990 patients met the inclusion criteria, of which 87% received local antibiotics. Higher risk patients were more likely to receive local antibiotics in the wound as part of their procedure. When controlling for potentially confounding factors, the use of local antibiotics was not statistically significantly associated with any of the studied adverse outcomes for the overall study population. Subgroup analysis of higher risk patient populations (≥13 levels fused, osteotomy performed, prior deformity surgery, nonasthma lung condition) revealed a significantly decreased risk of SSI in patients undergoing ≥13 level fusions (relative risk: 0.48, 95% confidence interval: 0.25-0.91).

CONCLUSIONS

With no increased overall risks and reduced SSIs in higher risk NMS patients undergoing PSF, the use of intrawound antibiotics appears to be supported by this dataset.