|SYMPOSIUM – POST SURGICAL SPINE INFECTION
|Year : 2018 | Volume
| Issue : 1 | Page : 2-6
Predisposing factors and protocols for prevention of surgical site infections following spine surgery: A review of literature
Suneetha Narreddy1, Venkata Ravikumar Chepuri2, Silpita Katragadda1, Ravikiran Abraham Barigala1, Raghava Dutt Mulukutla3
1 Department of Infectious Diseases, Apollo Health City, Hyderabad, Telangana, India
2 Department of Medicine, Rajiv Gandhi Institute of Medical Sciences, Kadapa, Andhra Pradesh, India
3 Department of Spine Surgery, Udai Omni and Apollo Health City, Hyderabad, Telangana, India
|Date of Web Publication||17-Jan-2018|
Dr. Suneetha Narreddy
Department of Infectious Diseases, Apollo Health City, Hyderabad, Telangana
Source of Support: None, Conflict of Interest: None
Surgical site infections (SSIs) following spinal surgery and its treatment are highly debated topics over decades, constituting one of the major causes of morbidity in patients undergoing spine surgery. The importance of this topic lies in the fact that, if ignored, it can lead to high morbidity and mortality, which may require prolonged hospitalization. This review deals with rates of SSI in various spine surgeries, then dwells on few studies exploring causes and prevention of SSI, provides a summary of SSI preventive protocols by various organizations, recommendations for antibiotic prophylaxis, and finally on medical management of established postoperative infections.
Keywords: Antibiotic prophylaxis, postoperative spine infection, predisposing factors
|How to cite this article:|
Narreddy S, Chepuri VR, Katragadda S, Barigala RA, Mulukutla RD. Predisposing factors and protocols for prevention of surgical site infections following spine surgery: A review of literature. Indian Spine J 2018;1:2-6
|How to cite this URL:|
Narreddy S, Chepuri VR, Katragadda S, Barigala RA, Mulukutla RD. Predisposing factors and protocols for prevention of surgical site infections following spine surgery: A review of literature. Indian Spine J [serial online] 2018 [cited 2018 Oct 17];1:2-6. Available from: http://www.isjonline.com/text.asp?2018/1/1/2/223445
| Introduction|| |
Postoperative surgical site infections (SSIs) drastically reduced with the introduction of principles of asepsis by Joseph Lister in the 1860s. However, despite modern antibiotics and aseptic precautions, we have not been able to eliminate postoperative infections altogether. SSIs prolong postoperative recovery with increased morbidity and mortality, defeating the very purpose of spine surgery, aimed at improving the quality of life (QOL) for the patient. Infections following spine surgery negatively affect patient QOL and impose a significant financial burden on the health care system. In addition to greater direct hospital costs, the patients with postoperative infections have more missed workdays. In light of these findings, efforts are being made to reduce the prevalence of wound infections following spinal surgery., Apart from universal aseptic precautions, spine surgery like other musculoskeletal surgeries requires antibiotic prophylaxis. The article summarizes the various protocols and measures followed to reduce SSI in the setting of spine surgery with a review of appropriate literature.
| Surgical Site Infections: Definition|| |
Centre for Disease Control and Prevention (CDC) proposed the following broad definitions for postoperative surgical site infections.
Superficial incision SSI:
- Occurs within 30 days of surgery
- Involves only the skin or subcutaneous tissue.
Deep incisional SSI:
- Occurs within 30 days of surgery when no implant or within 1 year with implant
- Involves deep tissues (fascial and/or muscle layers).
- Occurs within 30 days of surgery in no implant or within 1 year with implant
- Infection involves any part of the anatomy (e.g., organs and spaces), other than the incision, which was opened or manipulated during an operation.
A review of English literature in PubMed/Medline was performed with the following phrases: SSI, postoperative infections in spine surgery, prevention of SSIs, risk factors for SSI, protocols to reduce SSI, and the articles were evaluated to bring out the most relevant practices.
| Reported Rates of Surgical Site Infection|| |
Based on 108,419 spine surgery cases from the Scoliosis Research Society Morbidity and Mortality database, the overall rates of postoperative superficial and deep spinal infections were reported as 0.8% and 1.3%, respectively. Based on primary diagnosis, postoperative wound infection rate in adults was higher in patients with kyphosis (4.2%) than those that had degenerative disease (1.4%). The difference was noted in pediatric patients as well with infections in kyphosis as high as 5.4% compared to 0.9% in degenerative disease. Revision cases had a significantly higher rate of infection compared with primary cases (3.3% vs. 2.0%; P<.001). Revision surgery, spinal fusion, and use of implants were factors associated with increased rates of infection.
Causes and prevention of SSI: Infections following spine surgeries are usually a culmination of various events. Studies focused on identification of risk factors and interventions aimed at modifying those risk factors. A systematic review by Blood et al. classified the risk factors for postoperative spinal infections as patient-specific and operation-specific factors. Patient-specific factors were age, male gender, body mass index, alcoholism, tobacco use, diabetes mellitus, and a history of infection. Operative procedure-specific factors were preoperative cultures, antibiotic prophylaxis, duration of the procedure, use of implants, etc. Another study  suggested that malnourished patients are at extreme risk for postoperative infections of the spine. Protein and protein–calorie malnutrition are associated with poor wound healing, increased postoperative infections, and immune suppression. Most studies reported that following certain protocols resulted in a decreased rate of infections. Protocols of varies societies and organizations (NASS, CDC, AAOS, and WHO ) are constantly updated and are available as open access guidelines. Some of the recommendations and practices of surgical asepsis in spine surgery have been summarized in [Table 1]. Following the recommendations aimed at optimizing the preoperative status and addressing patient factors and operating room-specific factors are effective in reducing the risk of infection among patients undergoing spinal surgery. Other protective factors mentioned were the usage of chlorhexidine antiseptic for skin, placement of incision drains during the surgery, operating theater with laminar air flow, etc. Internal audits can help figure out local risk factors in individual hospitals and that knowledge can guide the implementation of preventative measures. Another prospective study done by Christodoulou et al. proposed a protocol for the assessment of risk factors called the “Nine Ps Protocol” comprising patient-related factors, personnel, place, preoperative length of stay, procedure, prosthetics, prophylaxis, packed red blood cells, and pus cultures. A total of 102 patients who underwent spinal surgery were divided into three groups before, during, and after the outbreak of infection, respectively. The protocol was applied to the third group, and a significant drop in infection was noted (16.7% to 3.6%). Another study suggests that prolonged duration of the procedure (lasting longer than 2–5 h), hemorrhage (exceeding 1000 ml), multiple level spinal fusion, implant placement, and simultaneous anterior and posterior fusion were contributory risk factors.
|Table 1: Common surgical practice recommendations for perioperative asepsis to prevent surgical site infections|
Click here to view
A significant source of infection is airborne bacterial inoculation during surgery. It has been reported that the patient's skin is the direct source of contamination in about 2% of cases, leaving 98% of contamination related to airborne particles. Surgical-site contamination by direct settling of airborne particles on the wound is seen in 30% of cases, and in 70% of cases, the contamination is by settling of particles on the instruments and surgeon's hands, followed by transfer to the wound. Periodical air and surface sample cultures may be valuable to the early identification of virulent bacteria colonies. Few studies report that, with the use of ultraclean air technology, the infection rate reduced in complex spinal procedures. However, laminar airflow failed to provide benefits according to some studies  and has been shown to increase early SSI rate in others.,, Further, using laminar airflow gives a false sense of security with frequent lapses in other aseptic precautions. Studies have also pointed out at limitations of laminar flow as it fails to extend to the instrumentation table.
Continuous evaluation of hand hygiene (HH) activities with people involved in nursing care activities and accurate detection and analysis of nurses activities could help improve HH practices. In long surgeries, it is observed that glove perforation occurs consistently after an average time of 90 min. With single gloving, perforation of the glove occurs in 15% of cases compared to only 5% with double gloving. It is recommended that double gloving is used routinely in all surgical procedures and the outer glove is changed every 90 min of the procedure to reduce contamination of the surgical site with hand flora. There is no evidence supporting the use of impregnated drapes to prevent spinal infections. These drapes added unnecessary cost and may decrease skin mobility, making adequate exposure more difficult [Table 1].
Use of local antibiotics, especially vancomycin powder, at the operative site has been practiced by many, and many studies have shown significantly decreased postsurgical wound infection rate in posterior instrumented thoracolumbar spine fusions., However, few studies have highlighted the increase in SSI with Gram-negative organisms with the routine use of vancomycin at the operative site. Implant surfaces are a risk factor for the formation of biofilm which is a potential nidus for bacterial infection, particularly staphylococci. The presence of the biofilm also decreases the penetration of antibiotic, thereby predisposing to antibiotic failure and emergence of antibiotic resistance. The practice of decolonizing patients who were found to be colonized with Staphylococcus aureus preoperatively has been mentioned in some studies; [Table 1] however, neither benefit nor the efficacy of this method has been established.
Antimicrobial prophylaxis: Antimicrobial prophylaxis should be used with appropriate protocols. Ideally, a broad-spectrum antibiotic which is known to penetrate the intervertebral disc should be administered prophylactically. In the setting of Gram-positive infections, cefazolin is the agent of choice. Clindamycin and vancomycin are acceptable alternatives for those with beta-lactam hypersensitivity. In the setting of risk for Gram-negative infection, agents such as aminoglycosides, aztreonam, or a fluoroquinolone can be used. Western literature is suggestive of Gram-positive bacteria causing SSIs, but the microbiogram in India is predominantly Gram-negative with variable drug-resistant patterns across the length and breadth of the country., This is important because it changes the choice of antibiotic. Boscardin et al. demonstrated that the therapeutic level of cefazolin was limited to a so-called golden period which appeared approximately 15–80 min after a high dose (2 g of cefazolin) had been administered. Studies have shown that single-dose prophylaxis is as effective as multidose prophylaxis.,, In fact, the unwarranted prolonged use of antibiotics increases the likelihood of developing infections by antibiotic-resistant bacteria, exposes patients to more adverse drug effects, and increases the overall medical cost. Redosing of the drugs should be done for prolonged surgeries. An experimental study by Walters et al. supports that timing of antibiotic prophylaxis is critical to prevent iatrogenic infection.
NASS  and AAOS  Guidelines on antibiotic prophylaxis.
| Recommendations|| |
- For typical uncomplicated cases, a single dose of preoperative prophylactic antibiotics with intraoperative redosing as needed is suggested to decrease the risk of SSI. Grade of Recommendation: B
- Prolonged postoperative regimens may be considered in complex situations (i.e, trauma, cord injury, neuromuscular disease, diabetes, or other comorbidities)
- Comorbidities and complex situations reviewed in the literature include obesity, diabetes, neurologic deficits, incontinence, preoperative serum glucose level of >125 mg/dL or a postoperative serum glucose level of >200 mg/dL, trauma, prolonged multilevel instrumented surgery, and other comorbidities. Grade of Recommendation: C
- Alternative regimens in complex situations – redosing, Gram-negative coverage, and the addition of intrawound application of vancomycin or gentamicin. Grade of recommendation: I (insufficient evidence)
- Which antibiotics?
- Cefazolin 1–2 g (2 g for >86 kg)/cefuroxime 1.5 g, within 60 min of incision. Single preoperative dose is sufficient. Redose for a prolonged procedure or significant blood loss. If using postoperative doses, discontinue within 24 h after wound closure. In case of beta-lactam allergy, use clindamycin or vancomycin prophylaxis. (AAOS guidelines)
- There is insufficient evidence to make a recommendation for or against the early discontinuation of antibiotic prophylaxis in patients with wound drains. Grade of recommendation: I (insufficient evidence).
(The complete recommendations are periodically updated and are available at NASS Web site http://www.spine.org/Pages/PracticePolicy/ClinicalCare/ClinicalGuidlines/Default.aspx).
Perioperative antibiotics: Even if some authors assume that postoperative doses of antibiotics can be administered during the first 24 h, we agree with CDC recommendations, who affirm that additional administrations have no value in terms of reducing the incidence of wound infections. This statement seems to be valid even in the presence of drains and epidural catheters. Among postoperative infections occurring after spinal surgery, iatrogenic discitis is one of the most common with its incidence ranging from 1% to 5%. Antibiotic penetration with parenteral administration to the avascular disc is not clearly understood, and hence intradiscal antibiotic administration is commonly used., Advocates cite surveys involving thousands of patients in which prophylactic antibiotics successfully prevented postoperative infection. On the other hand, opponents cite the low rate of postoperative infections in the preantibiotic era and emphasize the design flaws in the comparative studies that have been reported, particularly the absence of a placebo control.,
Medical treatment rationale in postoperative infections: Early recognition of postoperative infection is key to its management. The treatment of SSI should be culture dependent and may require the prolonged duration of antibiotics for 4–6 weeks, especially when the source cannot be removed.
| Conclusion|| |
Postoperative spine infection is a common but challenging complication, both in noninstrumented and instrumented spinal surgeries, as it can cause significant morbidity and may compromise the outcome of the surgery. Optimizing patient factors preoperatively, using prophylactic antibiotics, and following meticulous aseptic technique are the key to prevention. The risk factors of SSI for each patient need to be analyzed, and the modifiable factors should be addressed appropriately to minimize the risk. Although Gram-negative organisms are frequently isolated from postoperative wounds, S. aureus is the single most predominant pathogen isolated. In patients who still develop an infection despite efforts at prevention, timely diagnosis and treatment are critical. Judicious use of antibiotics along with evidence-based medicine is the need of the hour. A working knowledge of the most likely organism and the locally prevailing antibiotic sensitivity/resistance pattern will be of great help, especially in the situation where empirical treatment needs to be started. Apart from bacterial contamination of the wound, there are many other factors within the patient and his environment, which ultimately determine the outcome. Despite all the measures to reduce the incidence of SSI in spine surgery, we are still far away from attaining the goal of 0% SSI. Prevention, with the use of recommended preoperative protocols from global organizations (WHO, CDC, NICE, AAOS, and NASS), is probably the best way to reduce the incidence of SSI in spine surgery as of today.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
de Lissovoy G, Fraeman K, Hutchins V, Murphy D, Song D, Vaughn BB, et al.
Surgical site infection: Incidence and impact on hospital utilization and treatment costs. Am J Infect Control 2009;37:387-97.
Kuhns BD, Lubelski D, Alvin MD, Taub JS, McGirt MJ, Benzel EC, et al.
Cost and quality of life outcome analysis of postoperative infections after subaxial dorsal cervical fusions. J Neurosurg Spine 2015;22:381-6.
Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al.
Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect (Larchmt) 2013;14:73-156.
Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site infections, 1992: A modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol 1992;13:606-8.
Smith JS, Shaffrey CI, Sansur CA, Berven SH, Fu KM, Broadstone PA, et al.
Rates of infection after spine surgery based on 108,419 procedures: A report from the Scoliosis Research Society Morbidity and Mortality Committee. Spine (Phila Pa 1976) 2011;36:556-63.
Blood AG, Sandoval MF, Burger E, Halverson-Carpenter K. Risk and protective factors associated with surgical infections among spine patients. Surg Infect (Larchmt) 2017;18:234-49.
Klein JD, Garfin SR. Nutritional status in the patient with spinal infection. Orthop Clin North Am 1996;27:33-6.
Shaffer WO, Baisden JL, Fernand R, Matz PG, North American Spine Society. An evidence-based clinical guideline for antibiotic prophylaxis in spine surgery. Spine J 2013;13:1387-92.
Berríos-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, et al.
Centers for disease control and prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg 2017;152:784-91.
Prokuski L. Prophylactic antibiotics in orthopaedic surgery. J Am Acad Orthop Surg 2008;16:283-93.
Christodoulou AG, Givissis P, Symeonidis PD, Karataglis D, Pournaras J. Reduction of postoperative spinal infections based on an etiologic protocol. Clin Orthop Relat Res 2006;444:107-13.
Olsen MA, Nepple JJ, Riew KD, Lenke LG, Bridwell KH, Mayfield J, et al.
Risk factors for surgical site infection following orthopaedic spinal operations. J Bone Joint Surg Am 2008;90:62-9.
Chauveaux D. Preventing surgical-site infections: Measures other than antibiotics. Orthop Traumatol Surg Res 2015;101:S77-83.
Gruenberg MF, Campaner GL, Sola CA, Ortolan EG. Ultraclean air for prevention of postoperative infection after posterior spinal fusion with instrumentation: A comparison between surgeries performed with and without a vertical exponential filtered air-flow system. Spine (Phila Pa 1976) 2004;29:2330-4.
Pasquarella C, Pitzurra O, Herren T, Poletti L, Savino A. Lack of influence of body exhaust gowns on aerobic bacterial surface counts in a mixed-ventilation operating theatre. A study of 62 hip arthroplasties. J Hosp Infect 2003;54:2-9.
Merollini KM, Zheng H, Graves N. Most relevant strategies for preventing surgical site infection after total hip arthroplasty: Guideline recommendations and expert opinion. Am J Infect Control 2013;41:221-6.
Humphreys H. Surgical site infection, ultraclean ventilated operating theatres and prosthetic joint surgery: Where now? J Hosp Infect 2012;81:71-2.
Gastmeier P, Breier AC, Brandt C. Influence of laminar airflow on prosthetic joint infections: A systematic review. J Hosp Infect 2012;81:73-8.
Diab-Elschahawi M, Berger J, Blacky A, Kimberger O, Oguz R, Kuelpmann R, et al.
Impact of different-sized laminar air flow versus no laminar air flow on bacterial counts in the operating room during orthopedic surgery. Am J Infect Control 2011;39:e25-9.
Bardowski L, O'Donnell A, Zembower T, Lavin MA, Bolon M. Direct observation in the operating room:First step to best practices. Am J Infect Control 2009;37:E158-9.
Alijanipour P, Karam J, Llinás A, Vince KG, Zalavras C, Austin M, et al.
Operative environment. J Arthroplasty 2014;29:49-64.
Chin KR, London N, Gee AO, Bohlman HH. Risk for infection after anterior cervical fusion: Prevention with iodophor-impregnated incision drapes. Am J Orthop (Belle Mead NJ) 2007;36:433-5.
Sweet FA, Roh M, Sliva C. Intrawound application of vancomycin for prophylaxis in instrumented thoracolumbar fusions: Efficacy, drug levels, and patient outcomes. Spine (Phila Pa 1976) 2011;36:2084-8.
Bakhsheshian J, Dahdaleh NS, Lam SK, Savage JW, Smith ZA. The use of vancomycin powder in modern spine surgery: Systematic review and meta-analysis of the clinical evidence. World Neurosurg 2015;83:816-23.
Ghobrial GM, Thakkar V, Andrews E, Lang M, Chitale A, Oppenlander ME, et al.
Intraoperative vancomycin use in spinal surgery: Single institution experience and microbial trends. Spine (Phila Pa 1976) 2014;39:550-5.
Costerton JW. Biofilm theory can guide the treatment of device-related orthopaedic infections. Clin Orthop Relat Res 2005; 2005;437:7-11.
Kallen AJ, Wilson CT, Larson RJ. Perioperative intranasal mupirocin for the prevention of surgical-site infections: Systematic review of the literature and meta-analysis. Infect Control Hosp Epidemiol 2005;26:916-22.
Hawn MT, Richman JS, Vick CC, Deierhoi RJ, Graham LA, Henderson WG, et al.
Timing of surgical antibiotic prophylaxis and the risk of surgical site infection. JAMA Surg 2013;148:649-57.
Webster J, Osborne S. Preoperative bathing or showering with skin antiseptics to prevent surgical site infection. Cochrane Database Syst Rev 2012;9:CD004985. doi: 10.1002/14651858.
Tanner J, Norrie P, Melen K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev 2011;11:CD004122. doi: 10.1002/14651858.
Hadiati DR, Hakimi M, Nurdiati DS. Skin preparation for preventing infection following caesarean section. Cochrane Database Syst Rev 2012 Sep 12;(9):CD007462. doi: 10.1002/14651858.
Darouiche RO, Wall MJ Jr., Itani KM, Otterson MF, Webb AL, Carrick MM, et al.
Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med 2010;362:18-26.
Mastronardi L, Tatta C. Intraoperative antibiotic prophylaxis in clean spinal surgery: A retrospective analysis in a consecutive series of 973 cases. Surg Neurol 2004;61:129-35.
Negi V, Pal S, Juyal D, Sharma MK, Sharma N. Bacteriological profile of surgical site infections and their antibiogram: A Study from resource constrained rural setting of Uttarakhand State, India. J Clin Diagn Res 2015;9:DC17-20.
Mathur P, Singh S. Multidrug resistance in bacteria: A serious patient safety challenge for India. J Lab Physicians 2013;5:5-10.
] [Full text]
Boscardin JB, Ringus JC, Feingold DJ, Ruda SC. Human intradiscal levels with cefazolin. Spine (Phila Pa 1976) 1992;17:S145-8.
Rubinstein E, Findler G, Amit P, Shaked I. Perioperative prophylactic cephazolin in spinal surgery. A double-blind placebo-controlled trial. J Bone Joint Surg Br 1994;76:99-102.
Wimmer C, Gluch H, Franzreb M, Ogon M. Predisposing factors for infection in spine surgery: A survey of 850 spinal procedures. J Spinal Disord 1998;11:124-8.
McDonald M, Grabsch E, Marshall C, Forbes A. Single- versus multiple-dose antimicrobial prophylaxis for major surgery: A systematic review. Aust N
Z J Surg 1998;68:388-96.
Walters R, Rahmat R, Shimamura Y, Fraser R, Moore R. Prophylactic cephazolin to prevent discitis in an ovine model. Spine (Phila Pa 1976) 2006;31:391-6.
Walters R, Rahmat R, Fraser R, Moore R. Preventing and treating discitis: Cephazolin penetration in ovine lumbar intervertebral disc. Eur Spine J 2006;15:1397-403.
Malis LI. Prevention of neurosurgical infection by intraoperative antibiotics. Neurosurgery 1979;5:339-43.
Cushing H. Concerning the results of operations for brain tumor. JAMA 1915;64:189-95.
Cushing H. Experiences with the cerebellar astrocytomas: A critical review of seventy-six cases. Surg Gynecol Obstet 1931;52:129-4.