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

Surgical site infection prophylaxis with intra-wound vancomycin powder for uninstrumented spine surgeries: a meta-analysis

PURPOSE

It is unclear if intra-wound vancomycin powder significantly reduces the infection rate for uninstrumented spine surgery. The purpose of this study is to compare the rate of surgical site infection (SSI) in uninstrumented spine surgery that used vancomycin powder against controls.

METHODS

A search was performed on PUBMED/MEDLINE, Cochrane Database and Embase on 14 October 2022. Search keywords were "vancomycin, spine surgery, uninstrumented and spinal surgery." Instrumented cases were excluded. Type of surgery, type of treatment and incidence of infection among experimental or control were recorded.

RESULTS

288 articles were obtained from a literature search. 16 studies met inclusion criteria. 6/16 studies that reported on the infection rate using vancomycin were obtained. There were 1376 control cases with 20 cases of post-operative infection (1.45% overall). There were 795 cases that received prophylactic intra-wound vancomycin powder with 10 cases of infection reported (1.26%). There was no significant difference in infections between cases that received vancomycin compared to control. On subgroup analysis, studies that had a high rate of infection (Strom and Cannon) had a significant difference on the rate of infection with the use of vancomycin compared to control.

DISCUSSION AND CONCLUSION

The current study was unable to conclude that vancomycin decreased the rate of surgical site infections. Vancomycin use may be useful in populations that have a high rate of infection. Limitations in this study include the small number of studies that report on the use of vancomycin on uninstrumented spine surgery.

Evidence-based guideline for the prevention and management of perioperative infection

BACKGROUND

We have updated the guideline for preventing and managing perioperative infection in China, given the global issues with antimicrobial resistance and the need to optimize antimicrobial usage and improve hospital infection control levels.

METHODS

We conducted a comprehensive evaluation of the evidence for prevention and management of perioperative infection, based on the concepts of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The strength of recommendations was graded and voted using the Delphi method and the nominal group technique. Revisions were made to the guidelines in response to feedback from the experts.

RESULTS

There were 17 questions prepared, for which 37 recommendations were made. According to the GRADE system, we evaluated the body of evidence for each clinical question. Based on the meta-analysis results, recommendations were graded using the Delphi method to generate useful information.

CONCLUSIONS

This guideline provides evidence to perioperative antimicrobial prophylaxis that increased the rational use of prophylactic antimicrobial use, with substantial improvement in the risk-benefit trade-off.

Implementing an infection control checklist May not be effective in reducing the incidence of surgical site infections in spinal surgery

Background

Surgical site infections (SSI) in instrumented spine surgery remains as a major complication with increased morbidity. Although implementation of surgical safety checklists has been reported to lower the rates of SSI, reproducibility of these remain unclear.

Objective

The specific aim of this study was to explore the results of implementation of a SSI control protocol in regard to its efficacy in decreasing the rate of SSI.

Methods

A total of 140 instrumented spinal surgery cases between 2018 and 2021 were divided into two groups as Group 1 (checklist implemented) and Group 2 (control) and these were compared regarding SSI rates, patient rand surgery related factors, laboratory findings and infecting microorganisms.

Results

Ten SSIs were encountered in Group 1 (20.8%), whereas only nine in Group 2 (9.8%). Although not statistically significant (p > .05), these results highly favor the non-checklist implemented group regarding the development of SSI. A definitive infective microorganism could be identified in five out of 10 SSI in Group 1 and 6 out of nine in Group 2. Whereas only three out of 11 (27.3%) involved Gr (+) agents, rest of eight out of 11 (72.7%) involved Gr (-) agents.

Discussion

A failure in decreasing the SSI rate through the implementation of a SSI prevention checklist may be due to several factors pertaining to the study design, patient characteristics and the Gr (-) dominance in SSIs in our center. Nevertheless, this suggests that checklist implementation to prevent SSI in instrumented spine surgery may not be effective in all contexts.

OR Traffic and Surgical Site Infections: A Quality Improvement Project

Operating rooms are dynamic places with a lot of movement and people working as a concerted team. Operating room traffic can be necessary (eg, retrieving an unusual supply) or unnecessary (eg, a social visit). This quality improvement project aimed to reduce the amount of OR traffic to only necessary traffic and reduce the surgical site infection rates for the orthopedic ORs in a northern California community hospital. There were three principle interventions: door signs discouraging traffic, staff member relief in batches, and preference card review for accuracy. During the six-week post-intervention period, there were no reported surgical site infections for orthopedic procedures, and the standardized infection ratio decreased from 1.75 to 0 in 10 weeks. Operating room traffic decreased after implementation by 46.9%. The number of door openings per minute decreased from 1.96 per minute to 1.04 per minute at the project's conclusion. Staff members' awareness of OR traffic increased.

Skin Preparation Techniques for Orthopedic Foot and Ankle Surgery: A Current Concepts Review

Surgical site infection (SSI) following orthopedic foot and ankle surgery is associated with morbidity, mortality, and cost to the healthcare system. The local anatomy and physiology predispose patients undergoing procedures to elevated risk. In particular, sterilizing of the webspaces, nailfolds, and subungual areas presents challenges, and the preferred skin antisepsis technique for foot and ankle procedures has not yet been defined. Skin antiseptic solutions (SASs) consist of 3 main categories: alcohol, chlorhexidine, and iodine-based solutions. This review of the literature supports a combined chlorhexidine and alcohol preparation technique; however, there are a number of studies that suggest otherwise. In addition, there is variable evidence for the use of alternatives to the standard soft sponge application technique, including immersion, bristled brush, and cotton gauze application. These alternatives may have a particular advantage in the forefoot. Most studies to date use growth from skin swab cultures after skin preparation as the primary outcome. Higher-level studies with large subject populations and more meaningful clinical outcomes will be required to solidify guidelines for preoperative skin antisepsis prior to foot and ankle procedures.Level of Evidence: Level V, expert opinion.