Prevention of Surgical Site Infections in Adult Spine Surgery
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OverviewÂ
Surgical site infections (SSIs) continue to be a significant and costly complication in adult spinal surgery, despite efforts to reduce their occurrence. SSIs are associated with prolonged hospital stays, increased morbidity, and a higher risk of mortality. The Society for Healthcare Epidemiology of America (SHEA) estimates that up to 60% of SSIs can be prevented with evidence-based guidelines. Effective preventive measures should be considered during the preoperative, intraoperative, and postoperative phases to minimize the incidence of SSIs.
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.
If you are interested in knowing more about Prevention Of Surgical Site Infections In Adult Spine Surgery you have come to the right place!
Do you have more questions?Â
Is the use of intrawound vancomycin powder safe for all patients?
Yes, studies have shown that intrawound vancomycin powder is safe for most patients, with minimal adverse effects reported. However, it should be used with caution in patients with known allergies to vancomycin.
How does intrawound vancomycin powder work to prevent infections?
Intrawound vancomycin powder works by directly delivering high concentrations of the antibiotic to the surgical site, effectively killing bacteria that may cause infections.
What are the risks associated with prolonged use of postoperative antibiotics?
Prolonged use of postoperative antibiotics can lead to antibiotic resistance, increased risk of Clostridioides difficile infection, and adverse drug reactions.
Why is a single preoperative dose of antibiotics sufficient for non-instrumented spine surgeries?
A single preoperative dose of antibiotics is sufficient because it provides adequate prophylactic coverage during the critical period of bacterial exposure and surgical intervention.
How does closed suction wound drainage help in spine surgery?
Closed suction wound drainage helps by removing excess fluids and blood from the surgical site, which can prevent hematoma formation and promote healing
Are there any risks associated with using povidone-iodine solution for wound irrigation?
Povidone-iodine solution can be cytotoxic and neurotoxic, especially in cases involving dural exposure or injury. It should be avoided in these scenarios.
Why is preoperative hair removal with methods other than shaving recommended?
Preoperative hair removal with clipping or chemical depilation is recommended because these methods are less likely to cause skin abrasions that can lead to bacterial colonization and infections.
How does 2-octyl-cyanoacrylate skin closure compare to traditional sutures or staples?
2-octyl-cyanoacrylate provides a waterproof barrier, reduces infection rates, and often results in better cosmetic outcomes compared to traditional sutures or staples.
What are the benefits of using incisional negative pressure wound therapy (NPWT)?
NPWT helps reduce SSIs by maintaining a sterile environment, promoting wound healing, and reducing edema and exudate.
How do silver-impregnated dressings help prevent infections?
Silver-impregnated dressings have antimicrobial properties that inhibit bacterial growth and reduce the risk of infections in the wound area.
Are triclosan-coated sutures effective in reducing surgical site infections?
Yes, triclosan-coated sutures are effective in reducing SSIs by providing antimicrobial activity that prevents bacterial colonization on the suture material.
Why is regular glove replacement recommended during spine surgery?
Regular glove replacement reduces the risk of glove perforation and contamination, which can introduce bacteria into the surgical site.
Can gentamicin-collagen sponges be used in spine surgery to prevent SSIs?
While not yet widely used in spine surgery, gentamicin-collagen sponges have shown promise in reducing SSIs in other surgical fields and could potentially be beneficial in spine procedures.
How do iodine-impregnated surgical drapes prevent infections?
Iodine-impregnated drapes provide an antimicrobial barrier that reduces skin flora contamination during surgery.
How does total parenteral nutrition (TPN) increase the risk of infections?
TPN can increase the risk of infections due to factors such as central line-associated bloodstream infections and alterations in immune function.
What patient factors increase the risk of surgical site infections in spine surgery?
Patient factors such as obesity, diabetes, smoking, immunosuppression, and poor nutritional status increase the risk of SSIs.
Is there a risk of nephrotoxicity with the use of intrawound vancomycin?
No, the localized application of vancomycin powder in the wound does not typically result in nephrotoxic serum levels.
Can povidone-iodine solution be used for wound irrigation in cases with dural tears?
No, due to its potential neurotoxic effects, povidone-iodine solution should be avoided in cases involving dural tears.
What is the role of perioperative antibiotic prophylaxis in preventing SSIs?
Perioperative antibiotic prophylaxis reduces the bacterial load at the surgical site during the critical period of exposure, thereby preventing SSIs.
How effective is laminar airflow in preventing SSIs in spine surgery?
The effectiveness of laminar airflow in preventing SSIs in spine surgery is still debated, with some studies showing benefits and others indicating no significant impact or even increased infection rates.
Why is preoperative shaving associated with higher SSI rates?
Shaving can cause microabrasions on the skin, which increase the risk of bacterial colonization and subsequent infections.
What is the SCIP and how does it relate to SSI prevention?
The Surgical Care Improvement Project (SCIP) is an initiative aimed at reducing surgical complications, including SSIs, through evidence-based practices such as timely antibiotic prophylaxis.
What are the potential complications of using 2-octyl-cyanoacrylate for skin closure?
The most common complication of using 2-octyl-cyanoacrylate is seroma formation, but overall, it has a low incidence of adverse effects and is considered safe.
How does clipping compare to shaving for preoperative hair removal in terms of SSI prevention?
Clipping is associated with lower SSI rates compared to shaving because it causes less skin trauma and reduces the risk of bacterial colonization.
Dr. Vedant Vaksha
I am Vedant Vaksha, Fellowship trained Spine, Sports and Arthroscopic Surgeon at Complete Orthopedics. I take care of patients with ailments of the neck, back, shoulder, knee, elbow and ankle. I personally approve this content and have written most of it myself.
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