Prevention of Surgical Site Infections in Adult Spine Surgery

Although measures have been taken to decrease its occurrence, surgical site infection (SSI) continues to be a frequent and expensive complication of spinal surgery in adults. SSI has been found to be linked with longer hospital stays, higher rates of illness or disease, and increased risk of death.

The Society for Healthcare Epidemiology of America (SHEA) has made an estimation that evidence-based guidelines can prevent up to 60% of SSIs. Proactive measures should be considered during the preoperative, intraoperative, and postoperative phases to lower the incidence of SSI.

Intrawound Vancomycin Powder

The consensus of experts suggests that the application of vancomycin powder directly into a wound can lower the occurrence of surgical site infections.

Perioperative Antibiotic Prophylaxis

Giving a preoperative single dose of antibiotics decreases SSI rates compared to not giving any antibiotics. However, in non-instrumented lumbar spine surgery, giving multiple doses of antibiotics during the perioperative period does not impact SSI rates compared to giving a single preoperative dose.

Similarly, in instrumented lumbar fusion surgery, giving multiple doses of antibiotics during the perioperative period does not affect SSI rates compared to a single preoperative dose of antibiotics. When a single preoperative dose of antibiotics is given, administering postoperative antibiotics for three or more days does not impact SSI rates compared to administering postoperative antibiotics for only two days.

Closed Suction Wound Drainage

The utilization of a sealed suction drain for wound drainage does not impact the incidence of surgical site infections (SSIs).

Povidone-Iodine Solution Irrigation

The application of a 0.35% solution of povidone-iodine for wound irrigation diminishes the occurrence of surgical site infections (SSIs).

2-Octyl-Cyanoacrylate Skin Closure

According to the literature, the usage of 2-octylcyanoacrylate for skin closure results in lower surgical site infection (SSI) rates when compared to sutures or staples for skin closure. The safety record of intrawound vancomycin seems to be excellent, with a minimal occurrence of negative health outcomes.

With intrawound vancomycin usage in lumbar spine surgery, the incidence of negative outcomes is just 0.3%. The formation of a seroma is the most frequent complication. Likewise, in the pediatric spine literature, the treatment is deemed safe, with no indication of nephrotoxicity and non-toxic serum levels. A trend towards an increased incidence of gram-negative or polymicrobial infections has been noted.

Before a surgical operation, it is recommended to administer antibiotics to prevent infections. This practice is known as preoperative antibiotic prophylaxis and is a crucial component of the Surgical Care Improvement Project (SCIP), which aims to decrease surgical complications and fatalities.

The National Surgical Infection Prevention Project introduced this measure, and the North American Spine Society (NASS) Clinical Guidelines also recommend its use.

The NASS Clinical Guidelines reflect the consistent evidence that non-instrumented lumbar spine surgeries require only one preoperative intravenous (IV) antibiotic dose. This approach has been shown to be effective in multiple studies. As part of the SCIP measures, it is recommended to stop administering antibiotics within 24 hours of the surgical end time.

This is to prevent the unnecessary use of antibiotics, which can lead to the development of antibiotic-resistant bacteria. Literature has reported that administering antibiotics for an extended period after surgery while a drain is present can lower the incidence of surgical site infections (SSIs) in mastectomy and ventral hernia repair procedures.

Although closed suction wound drainage may not be necessary to prevent surgical site infections, it may still be suitable for other purposes, such as preventing hematoma formation.

Basic science studies have raised concerns about the potential neurotoxic effects of povidone-iodine in cases of dural injury. As a result, it has been recommended that povidone-iodine irrigation should be avoided in cases involving intradural work or dural tear. Furthermore, laboratory studies have demonstrated that povidone-iodine has cytotoxic effects on various types of cells, including osteoblasts, chondrocytes, fibroblasts, and mesenchymal stromal cells.

When compared to suture alone, the use of 2-octyl-cyanoacrylate in addition to suture for skin closure during cardiac surgery has been found to decrease the incidence of surgical site infections (SSIs). However, in studies involving open colectomy or total joint arthroplasty, the use of 2-octyl-cyanoacrylate did not result in a significant difference in SSI rates compared to the use of staples.

The majority of the available literature on the use of laminar airflow systems in the operating room has focused on orthopedic surgery, particularly total joint arthroplasty. Additionally, most of these studies have evaluated the effectiveness of combining laminar airflow systems with total body exhaust gowns.

Studies in the literature have indicated that the use of laminar airflow systems in the operating room can reduce the incidence of periprosthetic joint infections. However, some studies have also found a significant increase in surgical site infection rates associated with the use of laminar airflow systems.

The available literature from various disciplines suggests that preoperative hair removal through shaving is associated with an increased risk of surgical site infections (SSIs). Compared to shaving, methods such as clipping, chemical depilation, or no hair removal have significantly lower rates of surgical site infections (SSIs).

The increased risk of surgical site infections (SSIs) associated with razor use is believed to be due to a greater likelihood of injury to the skin barrier, which can lead to bacterial colonization. Additionally, if razors are reused and not properly sterilized, there is a risk of cross-contamination.

According to literature, a prospective randomized study conducted on patients undergoing radical cystectomy found that those who received total parenteral nutrition (TPN) in addition to their regular enteric intake had a higher incidence of surgical site infections (SSIs) and other infectious complications compared to the group who received enteric intake alone.

Despite the fact that the TPN group had their nutritional parameters restored earlier, the risk of infection was higher. The use of parenteral nutrition is associated with an increased risk of infectious complications, which is believed to be caused by multiple factors. This risk can potentially offset any benefits that may result from the accelerated recovery of nutritional parameters.

In regards to tissue that has been previously irradiated, the wound healing process may benefit from the vasodilatory effects of PGE. The use of incisional negative pressure wound therapy (NPWT) has been shown to decrease the incidence of surgical site infections (SSIs) in various surgical fields.

Silver is recognized for its antimicrobial characteristics, and, as a result, dressings that are impregnated with silver have been employed for a significant amount of time to prevent or treat infections in acute or chronic open wounds.

Triclosan is a type of antimicrobial substance that has an effect on both gram-positive and gram-negative bacteria, and is employed in a broad range of healthcare products. Coating sutures with antimicrobial agents has generated significant interest. The use of triclosan-coated sutures has been associated with a decrease in surgical site infections (SSI).

Previous studies in hip arthroplasty literature have demonstrated that regular glove replacement can reduce glove perforation and contamination. Similarly, in the spine literature, this practice has also been shown to be effective.

The use of surgical drapes impregnated with iodine is believed to aid in the prevention of surgical site infections (SSI) by decreasing contamination of the wound by skin flora, in addition to providing an antimicrobial effect.

The majority of prophylactic measures investigated thus far in adult spine surgery have been previously studied in other medical specialties for the prevention of surgical site infections (SSI) and were often initially developed and tested in those fields.

Proactive strategies that are currently under evaluation in other surgical fields, like the use of gentamicin-collagen sponges or antimicrobial skin sealants, are potential areas of investigation in the context of adult spine procedures. These interventions have undergone evaluation in other surgical domains, and their effectiveness has been to some extent confirmed, along with the availability of clinical safety data.

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