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Kazarian GS, Mok JK, Johnson M, Jordan YY, Hirase T, Subramanian T, Brause B, Kim HJ. Perioperative Infection Prophylaxis With Vancomycin is a Significant Risk Factor for Deep Surgical Site Infection in Spine Surgery. Spine (Phila Pa 1976) 2024; 49:1583-1590. [PMID: 38953398 DOI: 10.1097/brs.0000000000005081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 06/21/2024] [Indexed: 07/04/2024]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE The purpose of this study was to compare the efficacy of cefazolin versus vancomycin for perioperative infection prophylaxis. SUMMARY OF BACKGROUND DATA The relative efficacy of cefazolin alternatives for perioperative infection prophylaxis is poorly understood. MATERIALS AND METHODS This study was a single-center multisurgeon retrospective review of all patients undergoing primary spine surgery from an institutional registry. Postoperative infection was defined by the combination of three criteria: irrigation and debridement within 3 months of the index procedure, clinical suspicion for infection, and positive intraoperative cultures. Microbiology records for all infections were reviewed to assess the infectious organism and organism susceptibilities. Univariate and multivariate analyses were performed. RESULTS A total of 10,122 patients met inclusion criteria. The overall incidence of infection was 0.78%, with an incidence of 0.73% in patients who received cefazolin and 2.03% in patients who received vancomycin (OR: 2.83, 95% CI: 1.35-5.91, P= 0.004). Use of IV vancomycin (OR: 2.83, 95% CI: 1.35-5.91, P =0.006), BMI (MD: 1.56, 95% CI: 0.32-2.79, P =0.014), presence of a fusion (OR: 1.62, 95% CI: 1.04-2.52, P =0.033), and operative time (MD: 42.04, 95% CI: 16.88-67.21, P =0.001) were significant risk factors in the univariate analysis. In the multivariate analysis, only noncefazolin antibiotics (OR: 2.48, 95% CI: 1.18-5.22, P =0.017) and BMI (MD: 1.56, 95% CI: 0.32-2.79, P =0.026) remained significant independent risk factors. Neither IV antibiotic regimen nor topical vancomycin significantly impacted Gram type, organism type, or antibiotic resistance ( P >0.05). The most common reason for antibiosis with vancomycin was a penicillin allergy (75.0%). CONCLUSIONS Prophylactic antibiosis with IV vancomycin leads to a 2.5 times higher risk of infection compared with IV cefazolin in primary spine surgery. We recommend the routine use of IV cefazolin for infection prophylaxis, and caution against the elective use of alternative regimens like IV vancomycin unless clinically warranted.
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Affiliation(s)
- Gregory S Kazarian
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
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Chan V, Skaggs DL, Cho RH, Poon SC, Shumilak G. Characterizing antibiotic prophylaxis practices in pediatric deformity spinal surgery and impact on 30-day postoperative infection: an NSQIP pediatric database study. Spine Deform 2024; 12:979-987. [PMID: 38499968 DOI: 10.1007/s43390-024-00844-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/09/2024] [Indexed: 03/20/2024]
Abstract
PURPOSE The aim of this study was to characterize antibiotic prophylaxis practices in pediatric patients who have received posterior arthrodesis for spinal deformity and understand how these practices impact 30-day postoperative infection rates. METHODS This was a retrospective cohort study using the National Surgical Quality Improvement Program Pediatric database for year 2021. Patients 18 years of age or younger who received posterior arthrodesis for scoliosis or kyphosis correction were included. The outcome of interest was 30-day postoperative infection. Fisher's exact test and multivariable regression analysis were used to analyze the impact of intravenous antibiotic prophylaxis, intraoperative intravenous antibiotic redosing after 4 h, postoperative antibiotic prophylaxis, intraoperative topical antibiotics on 30-day postoperative infection, and various antibiotic prophylaxis regimens. RESULTS A total of 6974 patients were included in this study. The 30-day infection rate was 2.9%. Presurgical intravenous antibiotic (11.5% vs. 2.7%, p = 0.005), postoperative antibiotic (5.7% vs. 2.4%, p < 0.01), and intraoperative topical antibiotic (4.0% vs. 2.7%, p = 0.019) were associated with significantly reduced infection rates. There was no significant difference in infection rates between patients that received cefazolin versus vancomycin versus clindamycin. The addition of Gram-negative coverage did not result in significant differences in infection rates. Multivariable regression analysis found postoperative intravenous antibiotics and intraoperative topical antibiotics to reduce infection rates. CONCLUSIONS We found the use of presurgical intravenous antibiotics, postoperative intravenous antibiotics, and intraoperative topical antibiotics to significantly reduce infection rates. Results from this study can be applied to future research on implementation of standardized infection prevention protocols. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Vivien Chan
- UCLA Health, Los Angeles, 1131 Wilshire Blvd Suite 100, Santa Monica, CA, 90401, USA.
| | - David L Skaggs
- Spine Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Robert H Cho
- Shriners Children's Southern California, Pasadena, CA, USA
| | - Selina C Poon
- Shriners Children's Southern California, Pasadena, CA, USA
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Chan V, Shumilak G, Jafari M, Fehlings MG, Yang MMH, Skaggs DL. Risk stratification for early postoperative infection in Pediatric spinal deformity correction: development and validation of the Pediatric scoliosis infection risk score (PSIR score). EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024:10.1007/s00586-024-08359-7. [PMID: 38858267 DOI: 10.1007/s00586-024-08359-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 04/21/2024] [Accepted: 06/02/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND CONTEXT Postoperative infection after spinal deformity correction in pediatric patients is associated with significant costs. Identifying risk factors associated with postoperative infection would help surgeons identify high-risk patients that may require interventions to minimize infection risk. PURPOSE To investigate risk factors associated with 30-day postoperative infection in pediatric patients who have received posterior arthrodesis for spinal deformity correction. STUDY DESIGN/SETTING Retrospective review of prospectively collected data. PATIENT SAMPLE The National Surgical Quality Improvement Program Pediatric database for years 2016-2021 was used for this study. Patients were included if they received posterior arthrodesis for scoliosis or kyphosis correction (CPT 22,800, 22,802, 22,804). Anterior only approaches were excluded. OUTCOME MEASURES TThe outcome of interest was 30-day postoperative infection. METHODS Patient demographics and outcomes were analyzed using descriptive statistics. Multivariable logistic regression analysis using likelihood ratio backward selection method was used to identify significant risk factors for 30-day infection to create the Pediatric Scoliosis Infection Risk Score (PSIR Score). ROC curve analysis, predicted probabilities, and Hosmer Lemeshow goodness-of-fit test were done to assess the scoring system on a validation cohort. RESULTS A total of 31,742 patients were included in the study. The mean age was 13.8 years and 68.7% were female. The 30-day infection rate was 2.2%. Reoperation rate in patients who had a post-operative infection was 59.4%. Patients who had post-operative infection had a higher likelihood of non-home discharge (X2 = 124.8, p < 0.001). In our multivariable regression analysis, high BMI (OR = 1.01, p < 0.001), presence of open wound (OR = 3.18, p < 0.001), presence of ostomy (OR = 1.51, p < 0.001), neuromuscular etiology (OR = 1.56, p = 0.009), previous operation (OR = 1.74, p < 0.001), increasing ASA class (OR = 1.43, p < 0.001), increasing operation time in hours (OR = 1.11, p < 0.001), and use of only minimally invasive techniques (OR = 4.26, p < 0.001) were associated with increased risk of 30-day post-operative infection. Idiopathic etiology (OR = 0.53, p < 0.001) and intraoperative topical antibiotic use (B = 0.71, p = 0.003) were associated with reduced risk of 30-day postoperative infection. The area under the curve was 0.780 and 0.740 for the derivation cohort and validation cohort, respectively. CONCLUSIONS To our knowledge, this is the largest study of risk factors for infection in pediatric spinal deformity surgery. We found 5 patient factors (BMI, ASA, osteotomy, etiology, and previous surgery, and 3 surgeon-controlled factors (surgical time, antibiotics, MIS) associated with risk. The Pediatric Scoliosis Infection Risk Score (PSIR) Score can be applied for risk stratification and to investigate implementation of novel protocols to reduce infection rates in high-risk patients.
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Affiliation(s)
- Vivien Chan
- UCLA Health, 1131 Wilshire Blvd Suite 100, Los Angeles Santa Monica, CA, 90401, USA.
| | | | - Matiar Jafari
- UCLA Health, 1131 Wilshire Blvd Suite 100, Los Angeles Santa Monica, CA, 90401, USA
| | | | | | - David L Skaggs
- Spine Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Maisat W, Yuki K. Surgical site infection in pediatric spinal fusion surgery revisited: outcome and risk factors after preventive bundle implementation. PERIOPERATIVE CARE AND OPERATING ROOM MANAGEMENT 2023; 30:100308. [PMID: 36817803 PMCID: PMC9933986 DOI: 10.1016/j.pcorm.2023.100308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background Surgical site infections (SSI) contribute to significant morbidity, mortality, length of stay, and financial burden. We sought to evaluate the incidence and risk factors of surgical site infection following pediatric spinal fusion surgery in patients for whom standard perioperative antibiotic prophylaxis and preventive strategies have been implemented. Methods We conducted a retrospective study of children aged <18 years who underwent spinal fusion surgery from January 2017 to November 2021 at a quaternary academic pediatric medical center. Univariable analysis was used to evaluate associations between potential risk factors and SSI. Results Of 1111 patients, 752 (67.6%) were female; median age was 14.2 years. SSI occurred in 14 patients (1.3%). Infections were superficial incisional (n=2; 14.3%), deep incisional (n=9; 64.3%), and organ/space (n=3; 21.4%). Median time to SSI was 14 days (range, 8 to 45 days). Staphylococcus aureus and Escherichia coli were the most frequently-isolated bacteria. Potential risk factors for SSIs included low body weight (Odds ratio (OR) 0.96, 95% confidence interval (CI) 0.93-0.99, p=0.026), ASA classification of ≥3 (OR 24.53, 95%CI 3.20-188.22, p=0.002), neuromuscular scoliosis (OR 3.83, 95%CI 3.82-78.32, p<0.001), prolonged operative time (OR 1.56, 95%CI 1.28-1.92, p<0.001), prolonged anesthetic time (OR 1.65, 95%CI 1.35-2.00, p<0.001), administration of prophylactic antibiotic ≥60 minutes before skin incision (OR 11.52, 95%CI 2.34-56.60, p=0.003), and use of povidone-iodine alone for skin preparation (OR 5.97, 95%CI 1.27-28.06, p=0.024). Conclusion In the context of a robust bundle for SSI prevention; low body weight, ASA classification of ≥3, neuromuscular scoliosis, prolonged operative and anesthetic times, administration of prophylactic antibiotic ≥60 minutes before skin incision, and use of povidone-iodine alone for skin preparation increased the risk of SSI. Administration of prophylactic antibiotic within 60 minutes of skin incision, strict adherence to high-risk preventive protocol, and use of CHG-alcohol could potentially reduce the rate of SSI.
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Affiliation(s)
- Wiriya Maisat
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, USA
- Department of Anaesthesia, Harvard Medical School, Boston, USA
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Koichi Yuki
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, USA
- Department of Anaesthesia, Harvard Medical School, Boston, USA
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Mahan MA, Prasse T, Kim RB, Sivakanthan S, Kelly KA, Kashlan ON, Bredow J, Eysel P, Wagner R, Bajaj A, Telfeian AE, Hofstetter CP. Full-endoscopic spine surgery diminishes surgical site infections - a propensity score-matched analysis. Spine J 2023; 23:695-702. [PMID: 36708928 DOI: 10.1016/j.spinee.2023.01.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 12/15/2022] [Accepted: 01/18/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND CONTEXT Surgical site infections (SSI) are one the most frequent and costly complications following spinal surgery. The SSI rates of different surgical approaches need to be analyzed to successfully minimize SSI occurrence. PURPOSE The purpose of this study was to define the rate of SSIs in patients undergoing full-endoscopic spine surgery (FESS) and then to compare this rate against a propensity score-matched cohort from the National Surgical Quality Improvement Program (NSQIP) database. DESIGN This is a retrospective multicenter cohort study using a propensity score-matched analysis of prospectively maintained databases. PATIENT SAMPLE One thousand two hundred seventy-seven non-instrumented FESS cases between 2015 and 2021 were selected for analysis. In the nonendoscopic NSQIP cohort we selected data of 55,882 patients. OUTCOME MEASURES The occurrence of any SSI was the primary outcome. We also collected any other perioperative complications, demographic data, comorbidities, operative details, history of smoking, and chronic steroid intake. METHODS All FESS cases from a multi-institutional group that underwent surgery from 2015 to 2021 were identified for analysis. A cohort of cases for comparison was identified from the NSQIP database using Current Procedural Terminology of nonendoscopic cervical, thoracic, and lumbar procedures from 2015 to 2019. Trauma cases as well as arthrodesis procedures, surgeries to treat pathologies affecting more than 4 levels or spine tumors that required surgical treatment were excluded. In addition, nonelective cases, and patients with wounds worse than class 1 were also not included. Patient demographics, comorbidities, and operative details were analyzed for propensity matching. RESULTS In the non-propensity-matched dataset, the endoscopic cohort had a significantly higher incidence of medical comorbidities. The SSI rates for nonendoscopic and endoscopic patients were 1.2% and 0.001%, respectively, in the nonpropensity match cohort (p-value <.011). Propensity score matching yielded 5936 nonendoscopic patients with excellent matching (standard mean difference of 0.007). The SSI rate in the matched population was 1.1%, compared to 0.001% in endoscopic patients with an odds ratio 0.063 (95% confidence interval (CI) 0.009-0.461, p=.006) favoring FESS. CONCLUSIONS FESS compares favorably for risk reduction in SSI following spinal decompression surgeries with similar operative characteristics. As a consequence, FESS may be considered the optimal strategy for minimizing SSI morbidity.
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Affiliation(s)
- Mark A Mahan
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Tobias Prasse
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA; Department of Orthopedics and Trauma Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Robert B Kim
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | | | - Katherine A Kelly
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Osama N Kashlan
- Department of Neurological Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Jan Bredow
- Department of Orthopedics and Trauma Surgery, Krankenhaus Porz am Rhein, University of Cologne, Cologne, Germany
| | - Peer Eysel
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Ralf Wagner
- Ligamenta Spine Center, Frankfurt am Main, Germany
| | - Ankush Bajaj
- The Warren Alpert Medical School of Brown University, RI, USA
| | - Albert E Telfeian
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown, Rhode Island, USA
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Shaffer A, Naik A, MacInnis B, Chen M, Ivankovic S, Paisan G, Garst JR, Hassaneen W, Arnold PM. Perioperative prophylaxis for surgical site infections in pediatric spinal surgery: a systematic review and network meta-analysis. J Neurosurg Pediatr 2023; 31:43-51. [PMID: 36308474 DOI: 10.3171/2022.9.peds22316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/09/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Postoperative infections in pediatric spinal surgery commonly occur and necessitate reoperation(s). However, pediatric-specific infection prophylaxis guidelines are not available. This network meta-analysis compares perioperative prophylaxis methods including Betadine irrigation, saline irrigation, intrawound vancomycin powder, combination therapy (Betadine, vancomycin, gentamicin, and cefuroxime), Betadine irrigation plus vancomycin powder, and no intervention to determine the most efficacious prevention method. METHODS A systematic review was performed by searching the PubMed, EBSCO, Scopus, and Web of Science databases for peer-reviewed articles published prior to February 2022 comparing two or more infection prophylaxis methods in patients younger than 22 years of age. Data were extracted for treatment modalities, patient demographics, and patient outcomes such as total number of infections, surgical site infections, deep infections, intraoperative blood loss, operative time, follow-up time, and postoperative complications. Quality and risk of bias was assessed using National Institutes of Health tools. A network meta-analysis was performed with reduction of infections as the primary outcome. RESULTS Overall, 10 studies consisting of 5164 procedures were included. There was no significant difference between prophylactic treatment options in reduction of infection. However, three treatment options showed significant reduction in total infection compared with no prophylactic treatment: Betadine plus vancomycin (OR 0.22, 95% CI 0.09-0.54), vancomycin (OR 3.26, 95% CI 1.96-5.44), and a combination therapy (Betadine, vancomycin, gentamicin, and cefuroxime) (OR 0.24, 95% CI 0.07-0.75). P-Score hierarchical ranking estimated Betadine plus vancomycin to be the superior treatment to prevent total infections, deep infections, and surgical site infections (P-score 0.7876, 0.7175, and 0.7291, respectively). No prophylaxis treatment-related complications were reported. CONCLUSIONS The results of this network meta-analysis show the strongest support for Betadine plus vancomycin as a method to reduce infections following pediatric spinal surgery. There was heterogeneity among studies and inconsistent outcome reporting; however, three effective treatment options are identified.
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Affiliation(s)
- Annabelle Shaffer
- 1Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Illinois
| | - Anant Naik
- 1Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Illinois
| | - Bailey MacInnis
- 1Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Illinois
| | - Michael Chen
- 1Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Illinois
| | - Sven Ivankovic
- 2Department of Neurosurgery, University of Illinois College of Medicine, Peoria, Illinois
| | - Gabriella Paisan
- 3Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona; and
| | - Jonathan R Garst
- 2Department of Neurosurgery, University of Illinois College of Medicine, Peoria, Illinois
| | - Wael Hassaneen
- 1Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Illinois
- 4Department of Neurosurgery, Carle Foundation Hospital, Urbana, Illinois
| | - Paul M Arnold
- 1Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Illinois
- 4Department of Neurosurgery, Carle Foundation Hospital, Urbana, Illinois
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Best Practice Guidelines for Surgical Site Infection in High-risk Pediatric Spine Surgery: Definition, Prevention, Diagnosis, and Treatment. J Pediatr Orthop 2022; 42:e1008-e1017. [PMID: 36037438 DOI: 10.1097/bpo.0000000000002255] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Prior "best practice guidelines" (BPG) have identified strategies to reduce the risk of acute deep surgical site infection (SSI), but there still exists large variability in practice. Further, there is still no consensus on which patients are "high risk" for SSI and how SSI should be diagnosed or treated in pediatric spine surgery. We sought to develop an updated, consensus-based BPG informed by available literature and expert opinion on defining high-SSI risk in pediatric spine surgery and on prevention, diagnosis, and treatment of SSI in this high-risk population. MATERIALS AND METHODS After a systematic review of the literature, an expert panel of 21 pediatric spine surgeons was selected from the Harms Study Group based on extensive experience in the field of pediatric spine surgery. Using the Delphi process and iterative survey rounds, the expert panel was surveyed for current practices, presented with the systematic review, given the opportunity to voice opinions through a live discussion session and asked to vote regarding preferences privately. Two survey rounds were conducted electronically, after which a live conference was held to present and discuss results. A final electronic survey was then conducted for final voting. Agreement ≥70% was considered consensus. Items near consensus were revised if feasible to achieve consensus in subsequent surveys. RESULTS Consensus was reached for 17 items for defining high-SSI risk, 17 items for preventing, 6 for diagnosing, and 9 for treating SSI in this high-risk population. After final voting, all 21 experts agreed to the publication and implementation of these items in their practice. CONCLUSIONS We present a set of updated consensus-based BPGs for defining high-risk and preventing, diagnosing, and treating SSI in high-risk pediatric spine surgery. We believe that this BPG can limit variability in practice and decrease the incidence of SSI in pediatric spine surgery. LEVEL OF EVIDENCE Not applicable.
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Surgical Antimicrobial Prophylaxis in Neonates and Children Undergoing Neurosurgery: A RAND/UCLA Appropriateness Method Consensus Study. Antibiotics (Basel) 2022; 11:antibiotics11070856. [PMID: 35884111 PMCID: PMC9311924 DOI: 10.3390/antibiotics11070856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/17/2022] [Accepted: 06/22/2022] [Indexed: 11/25/2022] Open
Abstract
Pediatric neurosurgery is a highly specialized branch of surgery in which surgical site infections (SSIs) are potentially serious complications that can also adversely affect a good surgical outcome, compromising functional recovery and, in some cases, even putting the patient’s life at risk. The main aim of this consensus document is to provide clinicians with a series of recommendations on antimicrobial prophylaxis for neonates and children undergoing neurosurgery. The following scenarios were considered: (1) craniotomy or cranial/cranio-facial approach to craniosynostosis; (2) neurosurgery with a trans-nasal-trans-sphenoidal approach; (3) non-penetrating head injuries; (4) penetrating head fracture; (5) spinal surgery (extradural and intradural); (6) shunt surgery or neuroendoscopy; (7) neuroendovascular procedures. Patients undergoing neurosurgery often undergo peri-operative antibiotic prophylaxis, with different schedules, not always supported by scientific evidence. This consensus provides clear and shared indications, based on the most updated literature. This work has been made possible by the multidisciplinary contribution of experts belonging to the most important Italian scientific societies, and represents, in our opinion, the most complete and up-to-date collection of recommendations on the behavior to be held in the peri-operative setting in this type of intervention, in order to guide physicians in the management of the patient, standardize approaches and avoid abuse and misuse of antibiotics.
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Strom SF, Hess MC, Jardaly AH, Conklin MJ, Gilbert SR. Is it necessary to fuse to the pelvis when correcting scoliosis in cerebral palsy? World J Orthop 2022; 13:365-372. [PMID: 35582151 PMCID: PMC9048500 DOI: 10.5312/wjo.v13.i4.365] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 11/30/2021] [Accepted: 02/23/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Neuromuscular scoliosis is commonly associated with a large pelvic obliquity. Scoliosis in children with cerebral palsy is most commonly managed with posterior spinal instrumentation and fusion. While consensus is reached regarding the proximal starting point of fusion, controversy exists as to whether the distal level of spinal fusion should include the pelvis to correct the pelvic obliquity.
AIM To assess the role of pelvic fusion in posterior spinal instrumentation and fusion, particularly it impact on pelvic obliquity correction, and to assess if the rate of complications differed as a function of pelvic fusion.
METHODS This was a retrospective, cohort study in which we reviewed the medical records of children with cerebral palsy scoliosis treated with posterior instrumentation and fusion at a single institution. Minimum follow-up was six months. Patients were stratified into two groups: Those who were fused to the pelvis and those fused to L4/L5. The major outcomes were complications and radiographic parameters. The former were stratified into major and minor complications, and the latter consisted of preoperative and final Cobb angles, L5-S1 tilt and pelvic obliquity.
RESULTS The study included 47 patients. The correction of the L5 tilt was 60% in patients fused to the pelvis and 67% in patients fused to L4/L5 (P = 0.22). The pelvic obliquity was corrected by 43% and 36% in each group, respectively (P = 0.12). Regarding complications, patients fused to the pelvis had more total complications as compared to the other group (63.0% vs 30%, respectively, P = 0.025). After adjusting for differences in radiographic parameters (lumbar curve, L5 tilt, and pelvic obliquity), these patients had a 79% increased chance of developing complications (Relative risk = 1.79; 95%CI: 1.011-3.41).
CONCLUSION Including the pelvis in the distal level of fusion for cerebral palsy scoliosis places patients at an increased risk of postoperative complications. The added value that pelvic fusion offers in terms of correcting pelvic obliquity is not clear, as these patients had similar percent correction of their pelvic obliquity and L5 tilt compared to children whose fusion was stopped at L4/L5. Therefore, in a select patient population, spinal fusion can be stopped at the distal lumbar levels without adversely affecting the surgical outcomes.
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Affiliation(s)
- Shane F Strom
- Department of Orthopaedics, University of Alabama at Birmingham, Birmingham, Al 35294, United States
| | - Matthew C Hess
- Department of Orthopaedics, University of Alabama at Birmingham, Birmingham, Al 35294, United States
| | - Achraf H Jardaly
- Department of Orthopaedics, The Hughston Clinic/Hughston Foundation, Columbus, GA 31908, United States
| | - Michael J Conklin
- Department of Orthopaedics, University of Alabama at Birmingham, Birmingham, Al 35294, United States
| | - Shawn R Gilbert
- Department of Orthopaedics, University of Alabama at Birmingham, Birmingham, Al 35294, United States
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Staphylococcus aureus infections after elective pediatric surgeries. Infect Control Hosp Epidemiol 2022; 43:1625-1633. [DOI: 10.1017/ice.2021.462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Objective:
To determine the 180-day cumulative incidence of culture-confirmed Staphylococcus aureus infections after elective pediatric surgeries.
Design:
Retrospective cohort study utilizing the Premier Healthcare database (PHD).
Setting:
Inpatient and hospital-based outpatient elective surgical discharges.
Patients:
Pediatric patients <18 years who underwent surgery during elective admissions between July 1, 2010, and June 30, 2015, at any of 181 PHD hospitals reporting microbiology results.
Methods:
In total, 74 surgical categories were defined using ICD-9-CM and CPT procedure codes. Microbiology results and ICD-9-CM diagnosis codes defined S. aureus infection types: bloodstream infection (BSI), surgical site infection (SSI), and other types (urinary tract, respiratory, and all other). Cumulative postsurgical infection incidence was calculated as the number of infections divided by the number of discharges with qualifying elective surgeries.
Results:
Among 11,874 inpatient surgical discharges, 180-day S. aureus infection incidence was 1.79% overall (1.00% SSI, 0.35% BSI, 0.45% other). Incidence was highest among children <2 years of age (2.76%) and lowest for those 10–17 years (1.49%). Among 50,698 outpatient surgical discharges, incidence was 0.36% overall (0.23% SSI, 0.05% BSI, 0.08% others); it was highest among children <2 years of age (0.57%) and lowest for those aged 10–17 years (0.30%). MRSA incidence was significantly higher after inpatient surgeries (0.68%) than after outpatient surgeries (0.14%; P < .0001). Overall, the median days to S. aureus infection was longer after outpatient surgery than after inpatient surgery (39 vs. 31 days; P = .0116).
Conclusions:
These findings illustrate the burden of postoperative S. aureus infections in the pediatric population, particularly among young children. These results underscore the need for continued infection prevention efforts and longer-term surveillance after surgery.
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Sawires AN, Park PJ, Lenke LG. A narrative review of infection prevention techniques in adult and pediatric spinal deformity surgery. JOURNAL OF SPINE SURGERY (HONG KONG) 2021; 7:413-421. [PMID: 34734145 PMCID: PMC8511566 DOI: 10.21037/jss-21-10] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 05/20/2021] [Indexed: 06/13/2023]
Abstract
Spinal infections associated with pediatric and adult spinal deformity surgery are associated with postoperative morbidity and mortality along with elevated health-care costs. Prevention requires meticulous technique by the spine surgeon throughout the perioperative period. There is significant variability in the current practices of spinal deformity surgeons with regard to infection prevention, stemming from the lack of reliable evidence available in the literature. There has also been a lack of literature detailing the difference in infection rates and risk factors between pediatric and adult patients undergoing deformity correction surgery. In this narrative review we looked at 60 studies in the adult population and 9 studies in the pediatric population. Most of these studies of surgical site infections (SSI) in spinal deformity surgery have been performed in adult patients, however it is clear that the pediatric neuromuscular patient requires particular attention that we discuss in detail. This narrative review of the literature outlines evidence and compares and contrasts data for preventive strategies and modifiable risk factors to decrease rates of SSI in the pediatric and adult spinal deformity patient populations. In this review we discuss techniques relating to preoperative cleansing protocols, antibiotic administration, gentle soft tissue handling, appropriate closure, drain usage, and intraoperative technique itself to minimize EBL and operative time.
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Affiliation(s)
- Andrew N. Sawires
- Lenox Hill Hospital, Department of Orthopaedic Surgery, New York, NY, USA
| | - Paul J. Park
- Columbia University Irving Medical Center, Department of Orthopedic Surgery, New York, NY, USA
| | - Lawrence G. Lenke
- Columbia University Irving Medical Center, Department of Orthopedic Surgery, New York, NY, USA
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Watanabe K, Yamaguchi T, Suzuki S, Suzuki T, Nakayama K, Demura S, Taniguchi Y, Yamamoto T, Sugawara R, Sato T, Fujiwara K, Murakami H, Akazawa T, Kakutani K, Hirano T, Yanagida H, Watanabe K, Matsumoto M, Uno K, Kotani T, Takeshita K, Ohara T, Kawakami N. Surgical Site Infection Following Primary Definitive Fusion for Pediatric Spinal Deformity: A Multicenter Study of Rates, Risk Factors, and Pathogens. Spine (Phila Pa 1976) 2021; 46:1097-1104. [PMID: 33496537 DOI: 10.1097/brs.0000000000003960] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective multicenter study. OBJECTIVE To determine the surgical site infection (SSI) rate, associated risk factors, and causative pathogens in pediatric patients with spinal deformity. SUMMARY OF BACKGROUND DATA There have been no extensive investigations of the risk factors for SSI in Japan. METHODS Demographic data, radiographic findings, and the incidence of SSI were retrospectively analyzed in 1449 pediatric patients who underwent primary definitive fusion surgery for spinal deformity at any of 15 institutions from 2015 to 2017. SSI was defined according to the US Centers for Disease Control and Prevention guideline. RESULTS The incidence of all SSIs was 1.4% and that of deep SSIs was 0.76%. The most common pathogenic microbes were methicillin-resistant staphylococci (n = 5) followed by gram-negative rods (n = 4), methicillin-sensitive staphylococci (n = 1), and others (n = 10). In univariate analysis, younger age, male sex, a diagnosis of kyphosis, type of scoliosis, American Society of Anesthesiologists (ASA) class ≥3, mental retardation urinary incontinence, combined anterior-posterior fusion, greater magnitude of kyphosis, three-column osteotomy, use of blood transfusion, and number of antibiotic administration were associated with the likelihood of SSI (all P < 0.05). Multivariate logistic regression analysis identified the following independent risk factors for SSI: syndromic scoliosis etiology (vs. idiopathic scoliosis; adjusted odds ratio [OR] 16.106; 95% confidence interval [CI] 2.225-116.602), neuromuscular scoliosis etiology (vs. idiopathic scoliosis; adjusted OR 11.814; 95% CI 1.109-125.805), ASA class 3 (vs. class 2; adjusted OR 15.231; 95% CI 1.201-193.178), and administration of antibiotic therapy twice daily (vs. three times daily; adjusted OR 6.121; 95% CI 1.261-29.718). CONCLUSION The overall infection rate was low. The most common causative bacteria were methicillin-resistant followed by gram-negative rods. Independent risk factors for SSI in pediatric patients undergoing spinal deformity surgery were scoliosis etiology, ASA class 3, and administration of antibiotic therapy twice daily.Level of Evidence: 3.
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Affiliation(s)
- Kei Watanabe
- Department of Orthopaedic Surgery, Niigata University School of Medicine, Niigata City, Niigata, Japan
| | - Toru Yamaguchi
- Department of Orthopaedic Surgery, Fukuoka Children's Hospital, Higashi-ku, Fukuoka City, Fukuoka, Japan
| | - Satoshi Suzuki
- Department of Orthopaedic Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Teppei Suzuki
- Department of Orthopaedic Surgery, National Hospital Organization Kobe Medical Center, Suma-ku, Kobe City, Hyogo, Japan
| | - Keita Nakayama
- Department of Orthopaedic Surgery, Seirei Sakura Citizen Hospital, Sakura City, Chiba, Japan
| | - Satoru Demura
- Department of Orthopaedic Surgery, Kanazawa University School of Medicine, Kanazawa City, Ishikawa, Japan
| | - Yuki Taniguchi
- Department of Orthopaedic Surgery, Tokyo University School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Takuya Yamamoto
- Department of Orthopaedic Surgery, Red Cross Kagoshima Hospital, Kagoshima City, Kagoshima, Japan
| | - Ryo Sugawara
- Department of Orthopaedic Surgery, Jichi Medical University School of Medicine, Shimotsuke City, Tochigi, Japan
| | - Tatsuya Sato
- Department of Orthopaedic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Kenta Fujiwara
- Department of Orthopaedic Surgery, Osaka Medical College School of Medicine, Takatsuki City, Osaka, Japan
| | - Hideki Murakami
- Department of Orthopaedic Surgery, Iwate Medical University School of Medicine, Morioka City, Iwate, Japan
| | - Tsutomu Akazawa
- Department of Orthopaedic Surgery, St Marianna University School of Medicine, Miyamae-ku, Kawasaki City, Kanagawa, Japan
| | - Kenichiro Kakutani
- Department of Orthopaedic Surgery, Kobe University School of Medicine, chuou-ku, Kobe City, Hyogo, Japan
| | - Toru Hirano
- Department of Orthopaedic Surgery, Niigata University School of Medicine, Niigata City, Niigata, Japan
| | - Haruhisa Yanagida
- Department of Orthopaedic Surgery, Fukuoka Children's Hospital, Higashi-ku, Fukuoka City, Fukuoka, Japan
| | - Kota Watanabe
- Department of Orthopaedic Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Morio Matsumoto
- Department of Orthopaedic Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Koki Uno
- Department of Orthopaedic Surgery, National Hospital Organization Kobe Medical Center, Suma-ku, Kobe City, Hyogo, Japan
| | - Toshiaki Kotani
- Department of Orthopaedic Surgery, Seirei Sakura Citizen Hospital, Sakura City, Chiba, Japan
| | - Katsushi Takeshita
- Department of Orthopaedic Surgery, Jichi Medical University School of Medicine, Shimotsuke City, Tochigi, Japan
| | - Tetsuya Ohara
- Department of Orthopaedic Surgery, Meijo Hospital, Naka-ku, Nagoya City, Aichi, Japan
| | - Noriaki Kawakami
- Department of Orthopaedic Surgery, Meijo Hospital, Naka-ku, Nagoya City, Aichi, Japan
- Department of Orthopaedic Surgery, Ichinomiyanishi Hospital, Ichinomiya City, Aichi, Japan
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Prevention of surgical site infections in pediatric spines: a single-center experience. Childs Nerv Syst 2021; 37:2299-2304. [PMID: 33635418 DOI: 10.1007/s00381-021-05095-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 02/17/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE To describe the potential issues in the methodology of surgical site infection (SSI) prevention and how it was investigated and corrected in a single institution. METHODS A pediatric orthopedic unit experienced an increase of SSI, concerning up to 10% of scoliosis surgery cases from 2011 to 2013. An institutional procedure of multimodal and interdisciplinary risk evaluation was initiated, including a review of the literature, a morbi-mortality meeting, internal and external audits concerning the hygiene conditions in the operating room, the antibiotic prophylaxis, patients, and sterile material pathways. Several preventive actions were implemented, including the improvement of air treatment in the operating room, wound irrigation with 2L of saline before closure, application of topic vancomycine in the wound, verification of doses and timing of antibiotics injection, and use of waterproof bandages. We compared the rates of spine SSI before (retrospective group, 2011-2013) and after the implementation of various preventive measures (prospective group, 2014-2018). RESULTS SSI occurred in 12 patients (6 idiopathic and 6 neuromuscular) out of 120 operated on (93 idiopathic, 18 neuromuscular, 9 others) in the retrospective group and 2 (both neuromuscular) out of 196 (150 idiopathic, 33 neuromuscular,13 others) in the prospective group (10% vs 1%, odds ratio=9.7, p=0.001). The groups were comparable for age, etiology, duration of surgery, body mass index, American Society of Anesthesiologists score, number of levels fused, and blood loss (p>0.2). CONCLUSION The systematic analysis of SSI allowed for the understanding of the failures and correcting them. The current process is effectively preventing SSI. LEVEL OF EVIDENCE 3: prospective series with case-control analysis.
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Pennington Z, Cottrill E, Lubelski D, Ehresman J, Lehner K, Groves ML, Sponseller P, Sciubba DM. Clinical utility of enhanced recovery after surgery pathways in pediatric spinal deformity surgery: systematic review of the literature. J Neurosurg Pediatr 2021; 27:225-238. [PMID: 33254141 DOI: 10.3171/2020.7.peds20444] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 07/02/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVES More than 7500 children undergo surgery for scoliosis each year, at an estimated annual cost to the health system of $1.1 billion. There is significant interest among patients, parents, providers, and payors in identifying methods for delivering quality outcomes at lower costs. Enhanced recovery after surgery (ERAS) protocols have been suggested as one possible solution. Here the authors conducted a systematic review of the literature describing the clinical and economic benefits of ERAS protocols in pediatric spinal deformity surgery. METHODS The authors identified all English-language articles on ERAS protocol use in pediatric spinal deformity surgery by using the following databases: PubMed/MEDLINE, Web of Science, Cochrane Reviews, EMBASE, CINAHL, and OVID MEDLINE. Quantitative analyses of comparative articles using random effects were performed for the following clinical outcomes: 1) length of stay (LOS); 2) complication rate; 3) wound infection rate; 4) 30-day readmission rate; 5) reoperation rate; and 6) postoperative pain scores. RESULTS Of 950 articles reviewed, 7 were included in the qualitative analysis and 6 were included in the quantitative analysis. The most frequently cited benefits of ERAS protocols were shorter LOS, earlier urinary catheter removal, and earlier discontinuation of patient-controlled analgesia pumps. Quantitative analyses showed ERAS protocols to be associated with shorter LOS (mean difference -1.12 days; 95% CI -1.51, -0.74; p < 0.001), fewer postoperative complications (OR 0.37; 95% CI 0.20, 0.68; p = 0.001), and lower pain scores on postoperative day (POD) 0 (mean -0.92; 95% CI -1.29, -0.56; p < 0.001) and POD 2 (-0.61; 95% CI -0.75, -0.47; p < 0.001). There were no differences in reoperation rate or POD 1 pain scores. ERAS-treated patients had a trend toward higher 30-day readmission rates and earlier discontinuation of patient-controlled analgesia (both p = 0.06). Insufficient data existed to reach a conclusion about cost differences. CONCLUSIONS The results of this systematic review suggest that ERAS protocols may shorten hospitalizations, reduce postoperative complication rates, and reduce postoperative pain scores in children undergoing scoliosis surgery. Publication biases exist, and therefore larger, prospective, multicenter data are needed to validate these results.
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Affiliation(s)
| | | | | | | | | | | | - Paul Sponseller
- 2Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Surgical site infections in pediatric spinal surgery after implementation of a quality assurance program. Spine Deform 2021; 9:125-133. [PMID: 32875547 DOI: 10.1007/s43390-020-00192-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 08/10/2020] [Indexed: 01/28/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To assess the effectiveness of two infection-reducing programs in mitigating the incidence of post-operative surgical site infections (SSI) in pediatric patients after spinal deformity surgery at our institution. Infections following spinal deformity surgery are associated with higher morbidity as well as significantly increased healthcare costs. SSI in patients with neuromuscular etiologies is especially high, exceeding 8 percent for myelodysplasia patients and 6 percent for cerebral palsy patients. METHODS Manual chart review was conducted for 1934 pediatric spine procedures in 1200 patients at our institution between 2008 and 2018. Patients between the ages of 0 and 21 having any spinal surgical procedure including lengthening of growing rods were included. RESULTS Institution of two separate infection-reducing programs reduced risk of SSI in this population by 65.4%, when adjusted for age and number of instrumentation levels (risk ratio [RR] = 0.3, 95% confidence interval [CI] = 0.2; 0.6, p = 0.001). Patients undergoing Initial Instrumentation demonstrated 68.8% less risk of SSI compared to those who had other types of surgical procedures, after adjusting for age and the number of level instrumented (RR = 0.3, 95% CI 0.2; .6, p = 0.002). It was observed that the effect of each of these infection-reducing programs diminished with time. This effect was also observed with prior programs implemented at our institution. CONCLUSION The incidence of SSI decreased following the implementation of two infection-reducing programs especially in patients undergoing Initial Instrumentation procedures. However, time-series analysis suggests these programs may have maximal effect immediately following institution that diminishes with time. LEVEL OF EVIDENCE Level III.
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Yohe N, Ciminero M, Solomito M, Lee MC. Impact of Pediatric Subspecialty Training on Perioperative Complications in Adolescent Idiopathic Scoliosis Surgery. Orthopedics 2020; 43:e454-e459. [PMID: 32745224 DOI: 10.3928/01477447-20200721-11] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 07/25/2019] [Indexed: 02/03/2023]
Abstract
This was a retrospective study of data prospectively collected from 2012 to 2016 from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. The objective was to evaluate the effect of pediatric fellowship training on 30-day perioperative morbidity and mortality following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). Several pathways exist in North America by which physicians acquire the clinical and technical skills to manage AIS surgically. Previous work has noted that surgeons with pediatric fellowship training tend to perform the bulk of pediatric spine surgeries. However, no study has been performed that examines if pediatric fellowship training (PFT) has an impact on early postoperative outcomes. A total of 14,194 AIS surgical patients were identified from the ACS NSQIP database. A cohort receiving isolated PSF was abstracted from this group and separated into 3 groups according to surgeon training: (1) ped+ (with PFT, n=4455); (2) ped-(without PFT, n=325); and (3) ped+match (patients selected from ped+ matched to ped- for age, sex, and fusion levels, n=325). The groups were compared for 30-day perioperative morbidity and mortality. No significant differences were noted for the 3 groups in terms of wound infections, length of hospital stay, readmissions, and unplanned returns to the operating room. Ped+match and ped- groups had no difference in neurologic injury rates. However, the ped+ and ped+match groups had significantly lower rates of blood transfusion and average volume of blood lost compared with the ped- group. Surgeons with pediatric fellowship training have a significantly lower average blood loss volume and blood transfusion rate in PSF for AIS than surgeons without such training. Understanding that different training pathways for surgeons may directly impact operative outcomes invites further examination of surgical education in North America to improve training consistency. [Orthopedics. 2020;43(5):e454-e459.].
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Agarwal A, Kelkar A, Agarwal AG, Jayaswal D, Schultz C, Jayaswal A, Goel VK, Agarwal AK, Gidvani S. Implant Retention or Removal for Management of Surgical Site Infection After Spinal Surgery. Global Spine J 2020; 10:640-646. [PMID: 32677561 PMCID: PMC7359681 DOI: 10.1177/2192568219869330] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
STUDY DESIGN A literature review. OBJECTIVE To summarize the implant removal rate, common bacterial organisms found, time of onset, ratio of superficial to deep infection, and regurgitating the prevalence among all the retrospective and prospective studies on management and characterization of surgical site infections (SSIs). METHODS PubMed was searched for articles published between 2000 and 2018 on the management or characterization of SSIs after spinal surgery. Only prospective and retrospective studies were included. RESULTS A total of 49 articles were found relevant to the objective. These studies highlighted the importance of implant removal to avoid recurrence of SSI. The common organisms detected were methicillin-resistant Staphylococcus aureus, methicillin-resistant Staphylococcus epidermis, Staphylococcus epidermis, Staphylococcus aureus, and Propionibacterium acnes, with prevalence of 1% to 15%. A major proportion of all were deep SSI, with minority reporting on late-onset SSI. CONCLUSION Long-term antibiotics administration, and continuous irrigation and debridement were common suggestion among the authors; however, the key measure undertaken or implied by most authors to avoid risk of recurrence was removal or replacement of implants for late-onset SSI.
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Affiliation(s)
- Aakash Agarwal
- University of Toledo, Toledo, OH, USA,Aakash Agarwal, Department of Bioengineering and Orthopaedics Surgery, University of Toledo, 5051 Nitschke Hall, MS 303, 2801 West Bancroft Street, Toledo, OH 43606, USA.
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Antibiotic prophylaxis in high-risk pediatric spine surgery: Is cefazolin enough? Spine Deform 2020; 8:669-676. [PMID: 32207059 DOI: 10.1007/s43390-020-00092-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 02/17/2020] [Indexed: 10/24/2022]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE To describe pathogens found in SSI during pediatric-instrumented spine surgery, and to assess the relationship between pathogens and the etiology of the spinal deformity. Surgical site infection (SSI) after pediatric spine fusion is a well-known complication with incidence rates between 0.5 and 42%, associated with the patient underlying disorder. Pathogens involved in SSI seem to be related to patient characteristics, such as the etiology of the spinal deformity. GNB (gram-negative bacilli) are more frequent in neuropathic, muscular, and syndromic conditions. High-risk pediatric patients with a spine deformity undergoing instrumented surgery might benefit from receiving perioperative intravenous prophylaxis for GNB. METHODS We conducted a retrospective study at our tertiary-care pediatric hospital from January 2010 to January 2017. We reviewed records of all episodes of SSI that occurred in the first 12 months postoperatively. All patients who underwent instrumented spine surgery were included in this study. RESULTS We assessed 1410 pediatric-instrumented spine surgeries; we identified 68 patients with deep SSIs, overall rate of 4.8%. Mean age at instrumented spine surgery was 12 years and 9 months. Time elapsed between instrumented surgery and debridement surgery was 28.8 days. Cultures were positive in 48 and negative in 20. Of the 48 positive culture results, 41 (72%) were GNB, 12 (21%) gram-positive cocci (GPC), three (5%) gram-positive anaerobic cocci (GPAC), and one (2%) coagulase-negative staphylococci (CoNS). Of the 68 patients with primary SSIs, 46 were considered to have a high risk of infection, which reported GNB in 81%, GPC in 15%, GPAC in 2%, and CoNS in 2%. CONCLUSION Cefazolin prophylaxis covers GPC and CoNS, but GNB with unreliable effectiveness. Gram-negative pathogens are increasingly reported in SSIs in high-risk patients. Adding prophylaxis for GNB in high-risk patients should be taken into account when considering spine surgery. LEVEL OF EVIDENCE IV.
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Abstract
In July of 2018, the Second International Consensus Meeting (ICM) on Musculoskeletal Infection convened in Philadelphia, PA was held to discuss issues regarding infection in orthopedic patients and to provide consensus recommendations on these issues to practicing orthopedic surgeons. During this meeting, attending delegates divided into subspecialty groups to discuss topics specifics to their respective fields, which included the spine. At the spine subspecialty group meeting, delegates discussed and voted upon the recommendations for 63 questions regarding the prevention, diagnosis, and treatment of infection in spinal surgery. Of the 63 questions, 17 focused on the use of antibiotics in spine surgery, for which this article provides the recommendations, voting results, and rationales.
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Measures to reduce end-of-case wound contamination: the impact of intra-wound vancomycin powder and betadine irrigation on surgical site infections in posterior spinal fusion. Spine Deform 2020; 8:45-50. [PMID: 31981142 DOI: 10.1007/s43390-020-00033-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 07/11/2019] [Indexed: 10/25/2022]
Abstract
STUDY DESIGN Retrospective descriptive, single-center study. OBJECTIVES To determine the effect of standardized intrawound vancomycin powder and betadine irrigation on surgical site infection (SSI) rates after posterior spinal fusion (PSF) in idiopathic scoliosis. Since 2005, our pediatric spine center has implemented a series of changes to lower the risk of SSI. The most recent interventions-intrawound vancomycin powder and betadine irrigation-are applied just before closure, aiming to reduce the culture-positive bacterial contamination known to occur in many cases. We sought to determine the impact of these end-of-case measures on our center's SSI rate. METHODS We retrospectively reviewed patients who underwent PSF for idiopathic scoliosis at our institution from January 1, 2010, to June 30, 2018, identifying all cases that returned to the operating room for surgical debridement within 90 days of PSF. Cases were surgeon-audited to ensure inclusion of all infections that met Centers for Disease Control and Prevention (CDC) criteria for acute SSI. Vertical expandable prosthetic titanium ribs, growing rods, staged procedures, and nonidiopathic cases were excluded. Annual rates of SSIs were correlated with the initiation of each SSI prevention measure. RESULTS Among 740 cases of PSF for idiopathic scoliosis from 2010 to 2018, the overall acute SSI rate by CDC criteria was 0.68%. The idiopathic SSI rate dropped significantly, from 1.70 to 0.20%, after the standardized introduction of intrawound vancomycin powder and betadine irrigation before closure (p < 0.04). The implementation of these end-of-case measures in 2012-2013 was soon followed by an institution best 3.5-year SSI-free period for idiopathic cases. CONCLUSIONS Since intrawound vancomycin powder and betadine irrigation were added to our SSI prevention bundle, we have seen a significantly lower SSI rate after PSFs for idiopathic scoliosis. These findings suggest that anti-SSI interventions to reduce wound contamination at the end of the case may have a particularly positive impact on SSI reduction. LEVEL OF EVIDENCE Level III, therapeutic.
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Kalfas F, Severi P, Scudieri C. Infection with Spinal Instrumentation: A 20-Year, Single-Institution Experience with Review of Pathogenesis, Diagnosis, Prevention, and Management. Asian J Neurosurg 2019; 14:1181-1189. [PMID: 31903360 PMCID: PMC6896624 DOI: 10.4103/ajns.ajns_129_19] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Objective and Importance Instrumentation has become an integral component in the management of various spinal pathologies. The rate of infection varies from 2% to 20% of all instrumented spinal procedures. Postoperative spinal implant infection places patients at risk for pseudo-arthrosis, correction loss, spondylodiscitis, and adverse neurological sequelae and increases health-care costs. Materials and Methods We performed a cohort study of 1065 patients who underwent instrumented spinal procedures in our institution between 1995 and 2014. Fifty-one patients (4.79%) contracted postoperative spinal infection. Isolated bacterial species, infection severity, diagnosis/treatment timing, surgical/medical strategy treatment, and patient's medical background were evaluated to assess their relationship with management outcome. Results Multiple risk factors for postoperative spinal infection were identified. Infections may be early or delayed. C-reactive protein and magnetic resonance imaging are important diagnostic tools. Prompt diagnosis and aggressive therapy (debridement and parenteral antibiotics) were responsible for implant preservation in 49 of 51 cases, whereas implant removal noted in two cases was attributed to delayed treatment and uncontrolled infection with implant loosening or late infection with spondylodesis. Infection in the setting of instrumentation is more difficult to diagnose and treat due to biofilm. Conclusion Retention of the mechanically sound implants in early-onset infection permits fusion to occur, whereas delayed treatment and multiple comorbidities will most likely result in a lack of effectiveness in eradicating the infecting pathogens. An improved understanding of the role of biofilm and the development of newer spinal implants has provided insight into the pathogenesis and management of infected spinal implants. It is important to accurately identify and treat postoperative spinal infections. The treatment is multimodal and prolonged.
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Affiliation(s)
- Fotios Kalfas
- Department of Neurological Surgery, Galliera Hospitals, Genova, Italy
| | - Paolo Severi
- Department of Neurological Surgery, Galliera Hospitals, Genova, Italy
| | - Claudia Scudieri
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
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Minkara AA, Matsumoto H, Glotzbecker M, Samdani A, Flynn J, Vitale MG, Saiman L. A Multicenter Study of the Epidemiology of Deep Surgical Site Infections in Children With Nonidiopathic Early-Onset Scoliosis Including Associated Pathogens. Spine Deform 2019; 7:647-651. [PMID: 31202384 DOI: 10.1016/j.jspd.2018.11.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 11/13/2018] [Accepted: 11/20/2018] [Indexed: 01/13/2023]
Abstract
STUDY DESIGN Retrospective descriptive. OBJECTIVES Identify incidence and risk of deep surgical site infections (SSIs), associated pathogens, and antibiotic susceptibility in patients with nonidiopathic early-onset scoliosis (EOS) undergoing growth-friendly (GF) spine surgery. BACKGROUND SSIs following GF procedures for EOS are well described, but epidemiologic trends in associated pathogens have not been well characterized. METHODS The Children's Spine Study Group database was queried for children ≤18 years of age undergoing GF procedures for nonidiopathic EOS at 11 institutions from September 2001 to January 2016. Deep SSIs reported within 90 days of procedures were reviewed for associated pathogens and their susceptibility profiles. Data were analyzed to calculate incidence and risk. RESULTS 593 patients (median age 5.7 years, IQR 3.3-8.0 years) with scoliosis due to congenital (45%), neuromuscular (39%), and syndromic (16%) disorders underwent 5,072 procedures. The incidence of deep SSIs per patient was 12.6%; 75 patients had one or more deep SSIs. The risk of deep SSIs per procedure was 1.95% as 99 SSIs occurred after the 5072 procedures. Overall, 48% of deep SSIs followed expansion procedures. Pathogen(s) were cultured from 92% of SSIs including gram-positive cocci (GPC, 90.1%) and/or gram-negative rods (GNR, 17.6%). Methicillin-susceptible Staphylococcus aureus (48.4% of SSIs), methicillin-resistant S. aureus (23.1%), and coagulase negative staphylococci (CoNS, 8.8%) were the most common GPCs. Escherichia coli (5.5% of SSIs), Enterobacter cloacae (4.4%), and Pseudomonas aeruginosa (4.4%) were the most common among GNRs. GNR susceptibility to cefazolin was 41% during the study period, whereas GPC susceptibility to cefazolin was 59%. CONCLUSION The risk of SSIs can potentially be reduced for this vulnerable population by routinely reviewing the local epidemiology of SSIs, including the associated pathogens and their susceptibility patterns. As GNR susceptibility to cefazolin was only 41%, expanding prophylaxis to include aminoglycosides for GNR is prudent. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Anas A Minkara
- Columbia University Medical Center, 630 West 168th Street, New York, NY 10032, USA
| | - Hiroko Matsumoto
- Columbia University Medical Center, 630 West 168th Street, New York, NY 10032, USA
| | | | - Amer Samdani
- Shriners Hospitals for Children, 3551 N Broad St, Philadelphia, PA 19140, USA
| | - John Flynn
- Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19140, USA
| | - Michael G Vitale
- Columbia University Medical Center, 630 West 168th Street, New York, NY 10032, USA
| | - Lisa Saiman
- Columbia University Medical Center, 630 West 168th Street, New York, NY 10032, USA.
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- Children's Spine Foundation, Valley Forge, PA 19481, USA
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Mistovich RJ, Jacobs LJ, Campbell RM, Spiegel DA, Flynn JM, Baldwin KD. Infection Control in Pediatric Spinal Deformity Surgery: A Systematic and Critical Analysis Review. JBJS Rev 2019; 5:e3. [PMID: 28514262 DOI: 10.2106/jbjs.rvw.16.00071] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- R Justin Mistovich
- Division of Pediatric Orthopaedic Surgery, Case Western Reserve University School of Medicine, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Lloydine J Jacobs
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Robert M Campbell
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David A Spiegel
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - John M Flynn
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Keith D Baldwin
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Crews JD, Mina M, Johnson E, Guillen J, Simmons J, Joshi A. Risk Factors for Surgical Site Infections Following Vertical Expandable Prosthetic Titanium Rib (VEPTR) Surgery in Children. Spine Deform 2019; 6:791-796. [PMID: 30348360 DOI: 10.1016/j.jspd.2018.03.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 03/25/2018] [Accepted: 03/31/2018] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Case-control study. OBJECTIVES To identify risk factors for surgical site infections (SSIs) following vertical expandable prosthetic titanium rib (VEPTR) surgery in children. SUMMARY OF BACKGROUND DATA VEPTR surgery is a growth-sparing approach for early-onset scoliosis and chest or rib abnormalities. SSIs are an important complication following VEPTR surgery. We aimed to identify modifiable risk factors for SSIs following VEPTR surgery. METHODS Children who underwent VEPTR surgery at a tertiary-care children's hospital from January 2010 through November 2014 were included. SSIs following VEPTR implant or revision surgeries were identified. For each case patient, three control subjects matched by procedure type were randomly selected among those without infection. Patient and surgery-related risk factors were analyzed using conditional logistic regression. RESULTS Twenty-six infections occurred in 22 subjects following 326 VEPTR surgeries (SSI rate: 8.0%). The infection rate was greater among implant than revision surgeries (15.5% vs. 4.5%; p<.001). Methicillin-susceptible Staphylococcus aureus was the most common pathogen (50% of infections). On multivariate analysis, VEPTR SSI infections were associated with male gender (OR 3.5, 95% CI 0.9-13.2), assisted feeding (OR 4.5, 95% CI 1.0-20.3), administration of preoperative antibiotics more than 30 minutes before surgery (or >60 minutes for vancomycin) (OR 6.9, 95% CI 1.2-39.0), and an intraoperative temperature less than 35.0°C (OR 4.3, 95% CI 0.8-23.7). CONCLUSIONS Administration of preoperative antibiotics closer to the time of surgery may reduce the risk of SSI in children undergoing VEPTR surgery. Further study is needed to determine the optimal timing of antibiotic prophylaxis for children undergoing spinal surgery. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Jonathan D Crews
- Department of Pediatrics, Baylor College of Medicine, 315 N San Saba Street, Suite 1003, San Antonio, TX 78207, USA; Pediatric Infectious Diseases, Children's Hospital of San Antonio, 333 N. Santa Rosa Street, San Antonio, TX 78207, USA.
| | - Marina Mina
- Spinal and Thoracic Treatment and Research Center, Children's Hospital of San Antonio, 333 N. Santa Rosa Street, San Antonio, TX 78207, USA
| | - Eric Johnson
- Spinal and Thoracic Treatment and Research Center, Children's Hospital of San Antonio, 333 N. Santa Rosa Street, San Antonio, TX 78207, USA
| | - Janette Guillen
- Spinal and Thoracic Treatment and Research Center, Children's Hospital of San Antonio, 333 N. Santa Rosa Street, San Antonio, TX 78207, USA
| | - James Simmons
- Department of Pediatrics, Baylor College of Medicine, 315 N San Saba Street, Suite 1003, San Antonio, TX 78207, USA; Spinal and Thoracic Treatment and Research Center, Children's Hospital of San Antonio, 333 N. Santa Rosa Street, San Antonio, TX 78207, USA
| | - Ajeya Joshi
- Department of Pediatrics, Baylor College of Medicine, 315 N San Saba Street, Suite 1003, San Antonio, TX 78207, USA; Spinal and Thoracic Treatment and Research Center, Children's Hospital of San Antonio, 333 N. Santa Rosa Street, San Antonio, TX 78207, USA
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Imahiyerobo T, Minkara AA, Matsumoto H, Vitale MG. Plastic Multilayered Closure in Pediatric Nonidiopathic Scoliosis Is Associated With a Lower Than Expected Incidence of Wound Complications and Surgical Site Infections. Spine Deform 2019; 6:454-459. [PMID: 29886919 DOI: 10.1016/j.jspd.2017.12.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 12/11/2017] [Accepted: 12/15/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To compare the incidence of surgical site infection (SSI) and wound complications between standard and plastic multilayered closure (PMC) in patients with pediatric nonidiopathic scoliosis undergoing primary or revision instrumentation or fusion. STUDY DESIGN Retrospective cohort study. SUMMARY OF BACKGROUND DATA Although PMC has been used for adult spine patients as well as infected spinal wound closure, it has not been reported as routine closure in the pediatric nonidiopathic scoliosis population. METHODS Patients with nonidiopathic scoliosis undergoing primary or revision instrumentation or fusion between 2013 and 2016 were enrolled. Clinical charts and operative reports were reviewed. Following September 2015, all patients with nonidiopathic scoliosis received PMC closure by plastic or orthopedic surgery. The SSI and wound complication incidence in patients undergoing PMC was compared to standard closure. The mean Risk Severity Score (RSS) for SSI, which uses patient characteristics to calculate the excepted SSI probability, was compared to the observed (actual) incidence. The CDC definition of SSI (infection ≤90 days of surgery) was used. RESULTS 115 patients were identified, including 56 standard closure and 59 PMC (mean age of 10.6 years; 54.8% female; mean preoperative major curve = 57.5°). There was no significant difference in age, sex, race, preoperative major curve, BMI, hemoglobin, blood loss, mean RSS score, or etiology between both groups (p > .05). Following PMC implementation, the observed incidence of wound complications decreased significantly from 19.6% in standard closures to 5.1% in the PMC group (p = .02), and the SSI incidence decreased from 8.9% to 1.7% (p = .11). The overall change in the observed (actual) incidence versus expected (RSS score) incidence of SSI indicated a 7.1% reduction following PMC. CONCLUSION Utilizing PMC in patients undergoing spinal surgery for nonidiopathic scoliosis significantly decreases the incidence of wound complications. Surgeons should consider using PMC in patients with nonidiopathic scoliosis. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Thomas Imahiyerobo
- Columbia University Medical Center, 3959 Broadway, 8 North, New York, NY 10032, USA
| | - Anas A Minkara
- Columbia University Medical Center, 3959 Broadway, 8 North, New York, NY 10032, USA
| | - Hiroko Matsumoto
- Columbia University Medical Center, 3959 Broadway, 8 North, New York, NY 10032, USA.
| | - Michael G Vitale
- Columbia University Medical Center, 3959 Broadway, 8 North, New York, NY 10032, USA
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Surgical site infection following elective nonspinal paediatric orthopaedic surgery: a prospective review. J Pediatr Orthop B 2019; 28:89-93. [PMID: 30252792 DOI: 10.1097/bpb.0000000000000549] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The aim of this study was to determine the rate of surgical site infection (SSI) and the factors that predispose to it in children undergoing nonspinal orthopaedic surgery. Over a 6-month period, 326 children who underwent 334 nonspinal elective orthopaedic surgical procedures were prospectively reviewed for the development of surgical site infections. A total of 14 sites became infected, with an overall infection rate of 4.19%. All the infections were superficial, and the only causative organism detected was Staphylococcus aureus. Operating times longer than 1 h and surgical wounds greater than 10 cm in length were positively associated with SSIs. Although there were differences between male and females, type of admission, the use of prophylactic antibiotics, degree of wound contamination and the grades of surgeons, these differences were not statistically significant. The results of this prospective study provide valuable information that was not previously available to the practicing paediatric orthopaedic surgeon.
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Nasser R, Kosty JA, Shah S, Wang J, Cheng J. Risk Factors and Prevention of Surgical Site Infections Following Spinal Procedures. Global Spine J 2018; 8:44S-48S. [PMID: 30574437 PMCID: PMC6295823 DOI: 10.1177/2192568218806275] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
STUDY DESIGN Focused literature review. OBJECTIVE The objective of this article was to help identify potential risk factors as well as strategies to help prevent surgical site infections (SSIs) in spine surgery. METHODS An article search was performed using PubMed, EMBASE, and the Cochrane database of systematic reviews using the terms "surgery" OR "surgical" AND "spine" OR "spinal" AND "infection". Systematic review articles, meta-analyses, and clinical trials with more than 100 patients were reviewed. RESULTS Both patient and perioperative factors contribute to the development of SSIs. Patient factors such as smoking, obesity, diabetes, Methicillin-resistant Staphylococcus aureus (MRSA) colonization, and malnutrition are all modifiable risk factors that can lead to SSIs. Procedural steps, including preoperative MRSA screening and treatment for colonization, preoperative antibiotics, skin preparation, minimizing operative time, antibiotic or betadine irrigation, avoiding personnel turnover, and postoperative wound care have also been shown to decrease infection rates. CONCLUSION There are several measures a spine practitioner may be able to take in the preoperative, intraoperative, and postoperative settings. Protocols to counsel patients regarding modification of preexisting risk factors and ensure adequate antimicrobial therapy in the perioperative period may be developed to reduce SSIs in spine surgery.
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Affiliation(s)
- Rani Nasser
- University of Cincinnati, Cincinnati, OH, USA,Rani Nasser, Department of Neurological Surgery, University of Cincinnati, Cincinnati, OH 45219, USA.
| | | | - Sanjit Shah
- University of Cincinnati, Cincinnati, OH, USA
| | - Jeffrey Wang
- University of Southern California, Los Angeles, CA, USA
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Mueller K, Zhao D, Johnson O, Sandhu FA, Voyadzis JM. The Difference in Surgical Site Infection Rates Between Open and Minimally Invasive Spine Surgery for Degenerative Lumbar Pathology: A Retrospective Single Center Experience of 1442 Cases. Oper Neurosurg (Hagerstown) 2018; 16:750-755. [DOI: 10.1093/ons/opy221] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 07/17/2018] [Indexed: 01/06/2023] Open
Abstract
Abstract
BACKGROUND
Surgical site infection (SSI) in spinal surgery contributes to significant morbidity and healthcare resource utilization. Few studies have directly compared the rate of minimally invasive surgery (MIS) SSI with open surgery.
OBJECTIVE
To investigate whether MIS techniques had a lower SSI rate in degenerative lumbar procedures as compared with traditional open techniques.
METHODS
A single-center, retrospective review of a prospectively collected database was queried from January 2013 to 2016 for adult patients who underwent lumbar decompression and/or instrumented fusion for which the surgical indication involved degenerative disease. The SSI rate was determined for all procedures as well as in the open and minimally invasive groups. Risk factors associated with SSI were also reviewed for each patient.
RESULTS
A total of 1442 lumbar spinal procedures were performed during this time period. Of these, there were 961 MIS and 481 open (67% vs 33%, respectively). The overall SSI rate was 1.5% (21/1442). The surgical site infection rate for MIS was less than open techniques (0.5% vs 3.3%; P = .0003). For decompression only, the infection rate for MIS and open was 0.4% vs 3.9% (P = .04), and for decompression with fusion it was 0.7% vs 2.6%, respectively (P = .68).
CONCLUSION
Our study demonstrates a significant 7-fold reduction in SSIs when comparing MIS with open surgery. This significance was also demonstrated with a 10-fold reduction for procedures involving decompression alone. Procedures that require fusion as well as decompression showed a trend towards a decreased infection rate that did not reach clinical significance.
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Affiliation(s)
- Kyle Mueller
- Medstar Georgetown University Hospital, Department of Neurosurgery, Pasquerilla Healthcare Center (PHC), Washington, District of Columbia
| | - David Zhao
- Medstar Georgetown University Hospital, Department of Neurosurgery, Pasquerilla Healthcare Center (PHC), Washington, District of Columbia
| | - Osiris Johnson
- Georgetown University School of Medicine, Washington, District of Columbia
| | - Faheem A Sandhu
- Medstar Georgetown University Hospital, Department of Neurosurgery, Pasquerilla Healthcare Center (PHC), Washington, District of Columbia
| | - Jean-Marc Voyadzis
- Medstar Georgetown University Hospital, Department of Neurosurgery, Pasquerilla Healthcare Center (PHC), Washington, District of Columbia
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Himebauch AS, Sankar WN, Flynn JM, Sisko MT, Moorthy GS, Gerber JS, Zuppa AF, Fox E, Dormans JP, Kilbaugh TJ. Skeletal muscle and plasma concentrations of cefazolin during complex paediatric spinal surgery. Br J Anaesth 2018; 117:87-94. [PMID: 27317707 DOI: 10.1093/bja/aew032] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2015] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Surgical site infections (SSIs) can have devastating consequences for children who undergo spinal instrumentation. Prospective evaluations of prophylactic cefazolin in this population are limited. The purpose of this study was to describe the pharmacokinetics and skeletal muscle disposition of prophylactic cefazolin in a paediatric population undergoing complex spinal surgery. METHODS This prospective pharmacokinetic study included 17 children with adolescent idiopathic scoliosis undergoing posterior spinal fusion, with a median age of 13.8 [interquartile range (IQR) 13.4-15.4] yr and a median weight of 60.6 (IQR 50.8-66.0) kg. A dosing strategy consistent with published guidelines was used. Serial plasma and skeletal muscle microdialysis samples were obtained during the operative procedure and unbound cefazolin concentrations measured. Non-compartmental pharmacokinetic analyses were performed. The amount of time that the concentration of unbound cefazolin exceeded the minimal inhibitory concentration for bacterial growth for selected SSI pathogens was calculated. RESULTS Skeletal muscle concentrations peaked at a median of 37.6 (IQR 26.8-40.0) µg ml(-1) within 30-60 min after the first cefazolin 30 mg kg(-1) dose. For patients who received a second 30 mg kg(-1) dose, the peak concentrations reached a median of 40.5 (IQR 30.8-45.7) µg ml(-1) within 30-60 min. The target cefazolin concentrations for SSI prophylaxis for meticillin-sensitive Staphylococcus aureus (MSSA) and Gram-negative pathogens were exceeded in skeletal muscle 98.9 and 58.3% of the intraoperative time, respectively. CONCLUSIONS For children with adolescent idiopathic scoliosis undergoing posterior spinal fusion, the cefazolin dosing strategy used in this study resulted in skeletal muscle concentrations that were likely not to be effective for intraoperative SSI prophylaxis against Gram-negative pathogens.
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Affiliation(s)
- A S Himebauch
- Department of Anesthesiology and Critical Care Medicine Center for Clinical Pharmacology
| | - W N Sankar
- Department of Surgery, Division of Orthopedic Surgery
| | - J M Flynn
- Department of Surgery, Division of Orthopedic Surgery
| | - M T Sisko
- Department of Anesthesiology and Critical Care Medicine
| | | | - J S Gerber
- Department of Pediatrics, Division of Infectious Diseases
| | - A F Zuppa
- Department of Anesthesiology and Critical Care Medicine Center for Clinical Pharmacology
| | - E Fox
- Center for Clinical Pharmacology Department of Pediatrics, Division of Oncology, Perelman School of Medicine, University of Pennsylvania and The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - J P Dormans
- Division of Orthopedic Surgery, Texas Children's Hospital, Houston, TX 77030, USA
| | - T J Kilbaugh
- Department of Anesthesiology and Critical Care Medicine
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Compliance With a Comprehensive Antibiotic Protocol Improves Infection Incidence in Pediatric Spine Surgery. J Pediatr Orthop 2018; 38:287-292. [PMID: 27280896 PMCID: PMC5145789 DOI: 10.1097/bpo.0000000000000812] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND A multidisciplinary task force, designated Target Zero, has developed protocols for prevention of surgical site infection (SSI) for spine surgery at our institution. The purpose of this study was to evaluate how compliance with an antibiotic bundle impacts infection incidences in pediatric spine surgery. METHODS After institutional review board approval, a consecutive series of 511 patients (517 procedures) who underwent primary spine procedures from 2008 to 2012 were retrospectively reviewed to identify patients who developed SSI. Patients were followed for a minimum of 90 days postoperatively. Compliance data were collected prospectively in 511 consecutive patients and a total of 517 procedures. Three criteria were required for antibiotic bundle compliance: appropriate antibiotics completely administered within 1 hour before incision, antibiotics appropriately redosed intraoperatively for blood loss and time, and antibiotics discontinued within 24 hours postoperatively. A multivariable logistic regression analysis was used to test the association between compliance and the development of an infection. RESULTS Overall antibiotic bundle compliance rate was 85%. After adjusting for risk category, estimated blood loss, and study year, the likelihood of an infection was increased in the noncompliant group compared with the compliant group (adjusted odds ratio: 3.0, 95% CI, 0.96-9.47, P=0.0587). When expressed as the number needed to treat, strict adherence to antibiotic bundle compliance prevented 1 SSI within 90 days of surgery for every 26 patients treated with the antibiotic bundle. Reasons for noncompliance included failure to infuse preoperative antibiotics 1 hour before incision (10.3%), failure to redose antibiotics intraoperatively based on time or blood loss (5.5%), and failure to discontinue antibiotics within 24 hours postoperatively (1.9%). CONCLUSIONS Compliance with a comprehensive antibiotic protocol can lead to meaningful reductions in SSI incidences in pediatric spine surgery. Institutions should focus on improving compliance with prophylactic antibiotic protocols to decrease SSI in pediatric spine surgery. LEVEL OF EVIDENCE Level III-retrospective cohort study.
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Abstract
BACKGROUND Surgical site infections (SSIs) following spine surgery in children and adolescents with nonidiopathic scoliosis are associated with increased morbidity and health care costs. Potentially modifiable risk factors for SSIs merit additional study in this population. METHODS A single-center, retrospective cohort study was performed from August 2008 through December 2013 in children and adolescents undergoing surgery for nonidiopathic scoliosis to determine the trends in SSI rate and causative microorganisms. A standardized perioperative antimicrobial prophylaxis regimen was developed from September-October 2008. Potential risk factors for SSIs were assessed by multivariable analysis using Poisson regression models. Fusion procedures and growing construct procedures were analyzed separately. RESULTS In all, 268 patients underwent 536 surgical procedures of whom 192 underwent 228 fusion procedures, 89 underwent 308 growing construct procedures, and 13 underwent both procedures during the study period. Twenty-one SSIs (3.9% of surgical procedures and 7.8% of patients) occurred within 90 days of surgery, 17 SSIs occurred after fusion procedures (4.5% of procedures and 8.9% of patients), and 4 SSIs occurred after growing construct procedures (1.3% of procedures and 4.5% of patients). There were 9 polymicrobial SSIs (42.9%). Of the 31 bacterial pathogens isolated, 48% were Gram-negative organisms. Among patients undergoing fusion procedures, SSIs were associated with underdosing of preoperative cefazolin [relative risk (RR)=4.99; 95% confidence interval (CI), 1.89-17.43; P=0.012] and tobramycin (RR=5.86; 95% CI, 1.90-18.06; P=0.002), underdosing of intraoperative (RR=5.65; 95% CI, 2.13-14.97; P=0.001) and postoperative (RR=3.86; 95% CI, 1.20-12.40; P=0.023) tobramycin, and any preoperative or intraoperative underdosing (RR=4.89; 95% CI, 1.70-14.12; P=0.003), after adjustment for duration of surgery. No factors were associated with SSIs in those undergoing growing construct procedures. During the study period, the SSIs rate declined (P<0.0001). CONCLUSIONS Underdosing of tobramycin and preoperative cefazolin were associated with an increased SSI risk among patients undergoing fusion procedures. Future multicenter studies should further investigate the generalizability of these findings. LEVEL OF EVIDENCE Level II-retrospective study.
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Abstract
STUDY DESIGN Single-institution, retrospective case series. OBJECTIVE To determine whether the microbiology of deep surgical site infections (SSIs) after spinal fusion surgery for deformity has changed over the last decade at our institution. SUMMARY OF BACKGROUND DATA SSI after pediatric spinal deformity surgery results in significantly increased patient morbidity and health care costs. Although risk factors are multifactorial, prophylactic and treatment antibiotic coverage is based in part on historical epidemiologic data, which may evolve over time. METHODS This study represents a retrospective review of clinical and microbiology records of patients less than 21 years old who underwent spinal deformity surgery at a single institution between 2000 and 2012. Patients were included who underwent index surgery at our institution and developed a deep SSI. Patients with growth-preserving spine constructs were excluded. RESULTS The overall incidence of deep SSI was 3.6% (39/1094). The incidence of deep SSI following primary surgery was 3.3% (34/1034) and 8.3% (5/60) following revision surgery. The incidence of deep SSI varied by primary diagnosis: idiopathic (1.0%), neuromuscular (14.3%), syndromic (5.3%), congenital (5.7%), and kyphosis (0.0%). The most common inciting pathogens were Staphylococcus epidermidis (26%), methicillin-sensitive Staphylococcus aureus (MSSA, 18%), Propionibacterium acnes (P. acnes; 18%), and Escherichia coli (18%). Sixteen of the 18 (89%) gram-negative infections occurred in neuromuscular patients (P = 0.006). Between 2000 and 2006 and between 2007 and 2012, MSSA occurred in 2/18 (11%) and 5/21 (24%) of cases (P = 0.41), methicillin-resistant S. aureus occurred in 1/18 (6%) and 3/21 (14%) (P = 0.61), and P. acnes occurred in 3/18 (17%) and 4/21 (19%) (P = 1.0). CONCLUSION The epidemiology of deep SSI following spinal fusion for deformity in pediatric patients at our institution has not changed significantly during 13 years. Prophylactic antibiotic coverage for both gram-positive and gram-negative organisms may be indicated for patients with primary neuromuscular diagnoses. LEVEL OF EVIDENCE 4.
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Abstract
Complications following spine fusion for adolescent idiopathic scoliosis can be characterized as either intra-operative or post-operative. The most serious and feared complication is neurologic injury, both in the intra- and post-operative period. Other intra-operative complications include dural tears and ophthalmologic or peripheral nerve deficits, which may be related to positioning. Among the most common post-operative complications are surgical site infection, venous thromboembolism, gastrointestinal complications, and implant-related complications. Significant blood loss requiring transfusion, traditionally considered a known sequelae of spine fusion, is now being recognized as a "complication" in large national databases. Pediatric spine surgeons who care for patients with AIS must be thoroughly familiar with all potential complications and their management.
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Affiliation(s)
- Robert F Murphy
- Medical University of South Carolina, 96 Jonathan Lucas St, CSB 708, Charleston, SC, 29425, USA.
| | - James F Mooney
- Medical University of South Carolina, 96 Jonathan Lucas St, CSB 708, Charleston, SC, 29425, USA
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Sebaaly A, El Rachkidi R, Yaacoub JJ, Saliba E, Ghanem I. Management of spinal infections in children with cerebral palsy. Orthop Traumatol Surg Res 2016; 102:801-5. [PMID: 27480292 DOI: 10.1016/j.otsr.2016.04.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Revised: 04/09/2016] [Accepted: 04/13/2016] [Indexed: 02/02/2023]
Abstract
Cerebral palsy patients who undergo posterior spinal instrumentation for scoliosis are at a greater risk of surgical site infection compared to adolescents with idiopathic scoliosis. Many infecting organisms are reported. Risk factors include patients' specific factors, nutritional status as well as surgery related factors. Although surgical management is still controversial, it is always based on irrigation and debridement followed or not by implant removal. The purpose of this paper is to review the pathophysiology of surgical site infection in this patient population and to propose a treatment algorithm, based on a thorough review of the current literature and personal experience.
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Affiliation(s)
- A Sebaaly
- Department of orthopedic surgery, Hôtel Dieu de France, university hospital, faculty of medicine, Saint Joseph university, Mount Lebanon, Alfred Naccache street, Achrafieh, 166830 Beirut, Lebanon.
| | - R El Rachkidi
- Department of orthopedic surgery, Hôtel Dieu de France, university hospital, faculty of medicine, Saint Joseph university, Mount Lebanon, Alfred Naccache street, Achrafieh, 166830 Beirut, Lebanon
| | - J J Yaacoub
- Department of orthopedic surgery, Hôtel Dieu de France, university hospital, faculty of medicine, Saint Joseph university, Mount Lebanon, Alfred Naccache street, Achrafieh, 166830 Beirut, Lebanon
| | - E Saliba
- Department of orthopedic surgery, Hôtel Dieu de France, university hospital, faculty of medicine, Saint Joseph university, Mount Lebanon, Alfred Naccache street, Achrafieh, 166830 Beirut, Lebanon
| | - I Ghanem
- Department of orthopedic surgery, Hôtel Dieu de France, university hospital, faculty of medicine, Saint Joseph university, Mount Lebanon, Alfred Naccache street, Achrafieh, 166830 Beirut, Lebanon
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Borden TC, Bellaire LL, Fletcher ND. Improving perioperative care for adolescent idiopathic scoliosis patients: the impact of a multidisciplinary care approach. J Multidiscip Healthc 2016; 9:435-445. [PMID: 27695340 PMCID: PMC5028162 DOI: 10.2147/jmdh.s95319] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
The complex nature of the surgical treatment of adolescent idiopathic scoliosis (AIS) requires a wide variety of health care providers. A well-coordinated, multidisciplinary team approach to the care of these patients is essential for providing high-quality care. This review offers an up-to-date overview of the numerous interventions and safety measures for improving outcomes after AIS surgery throughout the perioperative phases of care. Reducing the risk of potentially devastating and costly complications after AIS surgery is the responsibility of every single member of the health care team. Specifically, this review will focus on the perioperative measures for preventing surgical site infections, reducing the risk of neurologic injury, minimizing surgical blood loss, and preventing postoperative complications. Also, the review will highlight the postoperative protocols that emphasize early mobilization and accelerated discharge.
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Affiliation(s)
- Timothy C Borden
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA, USA
| | - Laura L Bellaire
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA, USA
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Luhmann SJ, Smith JC. Preoperative MRSA Screening in Pediatric Spine Surgery: A Helpful Tool or a Waste of Time and Money? Spine Deform 2016; 4:272-276. [PMID: 27927516 DOI: 10.1016/j.jspd.2015.12.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Revised: 10/28/2015] [Accepted: 12/23/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To review the use of preoperative screening for Staphylococcus aureus for all pediatric spine procedures that was instituted at our facility in a multimodal approach to decrease the frequency of postoperative wound infections. SUMMARY OF BACKGROUND DATA Four years ago at our facility, a multimodal approach to decrease the frequency of postoperative infections after pediatric spine surgery was instituted. METHODS A single-center, single-surgeon pediatric spine surgery database was queried to identify all patients who had preoperative S. aureus nasal swab screening. Data collected included demographic data, diagnoses, methicillin-resistant S. aureus (MRSA) swab findings, bacterial antibiotic sensitivities, and outcome of the spine surgery. RESULTS A total of 339 MRSA screenings were performed. Twenty (5.9%) were MRSA positive, and 55 (16.2%) were methicillin-sensitive S. aureus (MSSA) positive. In the MRSA-positive group, 13 were neuromuscular, 5 were adolescent idiopathic scoliosis (AIS), 1 congenital, and 1 infantile idiopathic scoliosis. Of the MRSA-positive screenings, 13 (65.0% of MRSA-positive screenings; 3.8% of entire cohort) of were newly identified cases (9 neuromuscular, 3 AIS, and 1 congenital diagnoses). In the 55 MSSA-positive, 6 documented resistance to either cefazolin or clindamycin. Hence, in up to 22 of the preoperative screenings (6.5% of entire cohort; 16 MRSA and 6 MSSA showed antibiotic resistance), the preoperative antibiotic regimen could be altered to appropriately cover the identified bacterial resistances. During the study period, there were 11 patients who were diagnosed with a postoperative deep wound infection, none of them having positive screenings. CONCLUSION The use of preoperative nasal swab MRSA screening permitted adjustment of the preoperative antibiotic regimen in up to 6.5% of patients undergoing pediatric spine surgery. This inexpensive, noninvasive tool can be used in preoperative surgical planning for all patients undergoing spinal procedures. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Scott J Luhmann
- Department of Orthopaedic Surgery, Washington University School of Medicine, 660 S Euclid Ave, St. Louis, MO 63110, USA; St. Louis Children's Hospital, 1 Children's Place, St. Louis, MO 63110, USA; St. Louis Shriners Hospital, 4400 Clayton Ave, St. Louis, MO 63110, USA.
| | - June C Smith
- Department of Orthopaedic Surgery, Washington University School of Medicine, 660 S Euclid Ave, St. Louis, MO 63110, USA
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Wright ML, Skaggs DL, Matsumoto H, Woon RP, Trocle A, Flynn JM, Vitale MG. Does the Type of Metal Instrumentation Affect the Risk of Surgical Site Infection in Pediatric Scoliosis Surgery? Spine Deform 2016; 4:206-210. [PMID: 27927504 DOI: 10.1016/j.jspd.2015.11.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 10/22/2015] [Accepted: 11/10/2015] [Indexed: 11/16/2022]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES To determine the association of implant metal composition with the risk of surgical site infection (SSI) following pediatric spine surgery. SUMMARY OF BACKGROUND DATA SSI is a well-described complication following pediatric spine surgery. Many risk factors have been identified in the literature, but controversy remains regarding metal composition as a risk factor. METHODS This was a retrospective study of patients who underwent posterior spinal instrumentation procedures between January 1, 2006, and December 31, 2008, at three large children's hospitals for any etiology of scoliosis and had at least 1 year of postoperative follow-up. Procedures included posterior spinal fusion, growth-friendly instrumentation, and revision of spinal instrumentation. The Centers for Disease Control and Prevention definition of SSI was used. A chi-squared test was performed to determine the relationship between type of metal instrumentation and development of an SSI. RESULTS The study included 874 patients who underwent 1,156 total procedures. Overall, 752 (65%) procedures used stainless steel instrumentation, 238 (21%) procedures used titanium instrumentation, and the remaining 166 (14%) procedures used cobalt chrome and titanium hybrid instrumentation. The overall risk of infection was 6.1% (70/1,156) per procedure, with 5.9% (44/752) for stainless steel, 6.7% (12/238) for titanium, and 6.0% (10/166) for cobalt chrome. The multiple regression analysis found no significant differences in the metal type used between patients with and without infection (p = .886) adjusting for etiology, instrumentation to pelvis, and type of procedures. When stratified based on etiology, the multiple regression analyses also found no significant difference in SSI between two metal type groups. CONCLUSIONS This study found no difference in risk of infection with stainless steel, titanium, or cobalt chrome/titanium instrumentation and is adequately powered to detect a true difference in risk of SSI. LEVEL OF EVIDENCE Level II, prognostic.
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Affiliation(s)
- Margaret L Wright
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, USA.
| | | | - Hiroko Matsumoto
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Regina P Woon
- Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Ashley Trocle
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - John M Flynn
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michael G Vitale
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, USA
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A Novel Prevention Bundle to Reduce Surgical Site Infections in Pediatric Spinal Fusion Patients. Infect Control Hosp Epidemiol 2016; 37:527-34. [DOI: 10.1017/ice.2015.350] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUNDThe Surgical Care Improvement Project bundle emphasizes operative infection prevention practices. Despite implementing the Surgical Care Improvement Project bundle in 2008, spinal fusion surgical site infections (SF-SSI) continued to be prevalent for this low-volume, high-risk surgery.OBJECTIVETo design a combined pre-, peri-, and postoperative bundle (PPPB) that would lead to sustained reductions in SF-SSI rates.DESIGNQuality improvement project, before-after trial with cost-effectiveness analysis.SETTINGChildren’s hospital.PATIENTSAll spinal fusion patients, 2008–2015.INTERVENTIONA multidisciplinary team developed the PPPB composed of Surgical Care Improvement Project elements plus improved wound care practices, nursing standard of care, dedicated nursing unit, dermatology assessment tool and consultation, nursing education tool using “teach back” technique, and a “Back Home” kit. SF-SSI rates were compared before (2008–2010) and after (2011-February 2015) implementation of PPPB. PPPB compliance was monitored.RESULTSA total of 224 SF surgeries were performed from 2008 to February 2015. Pre-PPPB analysis revealed median time to SF-SSI of 28 days, secondary to skin and bowel flora. Mean 3-year pre-PPPB SF-SSI rate per 100 SF surgeries was 8.2 (8/98) (2008: 13.3 [4/30], 2009: 2.7 [1/37], 2010: 9.7 [3/31]). Mean SF-SSI rate after PPPB was 2.4 (3/126) (January 2011-February 2015); there was a 71% reduction in mean SSI rate (P=.0695). No SF-SSI occurred in neuromuscular patients (P=.008) after PPPB. Compliance with PPPB elements has been 100%.CONCLUSIONSPPPB led to sustained improvement in SF-SSI rates over 50 months. The PPPB could be reproduced for other surgeries.Infect Control Hosp Epidemiol 2016;37:527–534
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Surgical Site Infections in Pediatric Spine Surgery: Comparative Microbiology of Patients with Idiopathic and Nonidiopathic Etiologies of Spine Deformity. Pediatr Infect Dis J 2016; 35:66-70. [PMID: 26401984 DOI: 10.1097/inf.0000000000000925] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Surgical site infections (SSIs) are a concern in pediatric spine surgery with unusually high rates for a clean surgery and especially for patients with deformity of nonidiopathic etiology. Microbiologic differences between etiologies of spine deformities have been poorly investigated. METHODS We reviewed all cases of SSI in spinal surgery between 2007 and 2011. Characteristics of cases and of bacteria according to the etiology of the spine disease were investigated. RESULTS Of 496 surgeries, we identified 51 SSIs (10.3%) in 49 patients. Staphylococcus aureus was the most frequent pathogen whatever the etiology (n = 31, 61% of infection cases). The second most frequent pathogens vary according to the etiology of the spine deformity. It was Gram-negative bacilli (GNB) in nonidiopathic cases (n = 19, 45% of cases) and anaerobe in idiopathic cases (n = 8, 38% of cases), particularly Gram-positive anaerobic cocci (n = 5, 24% of cases). Infection rate was 6.8% in cases with idiopathic spine disease (n = 21) and 15.9% in cases with nonidiopathic spine disease (n = 30). Nonidiopathic cases were more frequently male with lower weight. American Society of Anesthesiologists score was more often greater than 2, they had more frequently sacral implants and postoperative intensive care unit stay. GNB were significantly associated with a nonidiopathic etiology, low weight, younger age and sacral fusion. SSIs were polymicrobial in 31% of cases with a mean of 1.4 species per infection cases. CONCLUSION S. aureus is the first cause of SSI in pediatric spine surgery. However, Gram-positive anaerobic cocci should be taken into account in idiopathic patients and GNB in nonidiopathic patients when considering antibiotic prophylaxis and curative treatment.
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Abstract
BACKGROUND Surgical site infections (SSIs) occur in approximately 700 pediatric patients annually and are associated with increased morbidity, mortality and cost. The aim of this study is to determine risk factors for SSI among pediatric patients undergoing craniotomy and spinal fusion. METHODS This is a retrospective case-control study. Cases were craniotomy or spinal fusion patients with SSI as defined by Centers for Disease Control and Prevention criteria with surgery performed from January 1, 2008 to July 31, 2009. For each case patient, 3 uninfected controls were randomly selected among patients who underwent the same procedure as the case patient within 1 month. We performed analyses of risk factors for craniotomy and spinal fusion SSI separately and as a combined outcome variable. RESULTS Underweight body mass index, increased time at lowest body temperature, increased interval to antibiotic redosing, the combination of vancomycin and cefazolin for prophylaxis, longer preoperative and postoperative intensive care unit stay and anticoagulant use at 2 weeks postoperatively were associated with an increased risk of SSI in the combined analysis of craniotomy and spinal fusion. Forty-seven percent of cases and 27% of controls received preoperative antibiotic doses that were inappropriately low because of their weight. CONCLUSIONS We identified modifiable risk factors for SSI including antibiotic dosing and body temperature during surgery. Preoperative antibiotic administration is likely to benefit from standard processes. Further studies of risk benefit for prolonged low body temperature during procedures are needed to determine the optimal balance between neuroprotection and potential immunosuppression associated with low body temperature.
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Sayama C, Willsey M, Chintagumpala M, Brayton A, Briceño V, Ryan SL, Luerssen TG, Hwang SW, Jea A. Routine use of recombinant human bone morphogenetic protein-2 in posterior fusions of the pediatric spine and incidence of cancer. J Neurosurg Pediatr 2015; 16:4-13. [PMID: 25860984 DOI: 10.3171/2014.10.peds14199] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The aim of this study was to determine the safety of recombinant human bone morphogenetic protein-2 (rhBMP-2) use in posterior instrumented fusions in the pediatric population, focusing on cancer risk. In a previous study, the authors reported the short-term (mean follow-up of 11 months) safety and efficacy of rhBMP-2 in the pediatric age group. The present study reports their results with a minimum of 24 months' follow-up. METHODS The authors retrospectively reviewed 57 consecutive cases involving pediatric patients who underwent posterior occiptocervical, cervical, thoracic, lumbar, or lumbosacral spine fusion from October 1, 2007, to June 30, 2011, at Texas Children's Hospital. Seven cases were excluded from further analysis because of loss to follow-up. Three patients died during the follow-up period and were placed in a separate cohort. RESULTS The patients' average age at the time of surgery was 11 years, 4 months (range 9 months to 20 years). The mean duration of follow-up was 48.4 months (range 24-70 months). Cancer status was determined at the most recent encounter with the patient and/or caretaker(s) in person, or in telephone follow-up. Twenty-four or more months after administration of rhBMP-2, there were no cases of new malignancy, degeneration, or metastasis of existing tumors. The cause of death of the patients who died during the study period was not related to BMP or to the development, degeneration, or metastasis of cancer. CONCLUSIONS Despite the large number of adult studies reporting increased cancer risk associated with BMP use, the authors' outcomes with rhBMP-2 in the pediatric population suggest that it is a safe adjunct to posterior spine fusions of the occipitocervical, cervical, thoracic, lumbar, and lumbosacral spine. There were no new cases of cancer, or degeneration or metastasis of existing malignancies in this series.
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Affiliation(s)
- Christina Sayama
- Neuro-Spine Program, Division of Pediatric Neurosurgery, and.,Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Matthew Willsey
- Neuro-Spine Program, Division of Pediatric Neurosurgery, and.,Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Murali Chintagumpala
- Neuro-oncology Program, Division of Hematology-Oncology, Department of Pediatrics, Texas Children's Hospital; and
| | - Alison Brayton
- Neuro-Spine Program, Division of Pediatric Neurosurgery, and.,Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Valentina Briceño
- Neuro-Spine Program, Division of Pediatric Neurosurgery, and.,Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Sheila L Ryan
- Neuro-Spine Program, Division of Pediatric Neurosurgery, and.,Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Thomas G Luerssen
- Neuro-Spine Program, Division of Pediatric Neurosurgery, and.,Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Steven W Hwang
- Division of Pediatric Neurosurgery, Floating Children's Hospital; and.,Department of Neurosurgery, Tufts University, Boston, Massachusetts
| | - Andrew Jea
- Neuro-Spine Program, Division of Pediatric Neurosurgery, and.,Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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Subramanyam R, Schaffzin J, Cudilo EM, Rao MB, Varughese AM. Systematic review of risk factors for surgical site infection in pediatric scoliosis surgery. Spine J 2015; 15:1422-31. [PMID: 25796355 DOI: 10.1016/j.spinee.2015.03.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 01/30/2015] [Accepted: 03/07/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Risk factors for surgical site infection (SSI) in children derived from the studies in the adult population are potentially misleading because of differences in pathophysiology and management. PURPOSE This systematic review addresses the key question: What are the risk factors for SSI in pediatric patients undergoing scoliosis surgery? STUDY DESIGN This is a qualitative systematic literature review. PATIENT SAMPLE Retrospective and observational trials of children undergoing scoliosis surgery reported on the occurrence of risk factors for SSI and the occurrence of SSI. METHODS Pubmed (Medline), Ovid Evidence-Based Medicine Reviews (EBMR), Scopus, and Cumulative Index to Nursing and Allied Health (CINAHL) were searched electronically for relevant articles in all the languages between January 1, 1991 and August 27, 2012, and cross-references were checked. Two independent reviewers identified articles and appraised quality with the Agency for Healthcare Research and Quality (AHRQ) criteria based on a weighted scoring of 0 to 100. RESULTS Our search identified 135 abstracts and 14 studies meeting the inclusion criteria. The AHRQ grading showed that five articles were high quality with a score of greater than 67, and five articles were moderate quality with a score between 50 and 67. The percent agreement between the two independent reviewers was 84%, and kappa agreement score was 0.91 (95% confidence interval [CI]: 0.78-1.03). There were 76 risk factors identified, of which 22 factors were reported in more than one study. Odds ratios and 95% CIs were reported inconsistently. Pooled p analysis of high- and moderate-quality articles identified five risk factors predictive of SSI: inappropriate antibiotic use (p=.001), neuromuscular scoliosis (p=.014), instrumentation (p=.023), increased hospital stay days (p=.003), and residual postoperative curve (p=.003). CONCLUSIONS The systematic review identified inappropriate antibiotic use, neuromuscular scoliosis, instrumentation, increased hospital stay days, and residual postoperative curve as risk factors for SSI after pediatric scoliosis surgery.
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Affiliation(s)
- Rajeev Subramanyam
- Department of Anesthesiology and Department of Pediatrics, 3333 Burnet Ave, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA.
| | - Joshua Schaffzin
- Department of Pediatrics, Hospital Medicine, 3333 Burnet Ave, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Elizabeth M Cudilo
- Weill Cornell Medical College, New York Presbyterian Hospital, Department of Anesthesiology, 525 E 68th Street, New York, NY 10065, USA
| | - Marepalli B Rao
- Department of Biostatistics, 247 Kettering Lab, University of Cincinnati, Cincinnati, OH 45221, USA
| | - Anna M Varughese
- Department of Anesthesiology and Department of Pediatrics, 3333 Burnet Ave, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA
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Meng F, Cao J, Meng X. Risk factors for surgical site infection following pediatric spinal deformity surgery: a systematic review and meta-analysis. Childs Nerv Syst 2015; 31:521-7. [PMID: 25707483 DOI: 10.1007/s00381-015-2659-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 02/12/2015] [Indexed: 01/11/2023]
Abstract
PURPOSE This study was conducted to identify risk factors for postoperative infection after pediatric spinal deformity surgery. METHODS A systematic electronic literature search from inception to November 2014 was performed in the following databases: Pubmed, Embase, and Cochrane library databases. Pooled odds ratios (ORs) or standardized mean differences (SMDs) with 95 % confidence intervals (CIs) were calculated using random or fixed effects model. Newcastle-Ottawa scale was used to evaluate the methodological quality, and Stata 11.0 was used to analyze data. RESULTS The main factors associated with infection after spinal surgery were idiopathic scoliosis (OR, 0.303; 95 % CI, 0.202-0.453), neuromuscular scoliosis (OR, 2.269; 95 % CI, 1.576-3.267), ambulatory status (OR, 0.241; 95 % CI, 0.078-0.747), previous spinal surgery (OR, 4.564; 95 % CI, 1.892-11.009), sacral vertebrae fused (OR, 2.717; 95 % CI, 1.836-4.020), and allograft (OR, 8.498; 95 % CI, 4.030-17.917). There was no sufficient evidence to reveal that male gender, age, body mass index, preoperative curve, preoperative urinary tract infection, combined anterior-posterior approach, estimated blood loss, and operating room time could lead to infection after spinal surgery. CONCLUSIONS We identified some risk factors which could be used to prevent the onset of surgical site infection in pediatric spinal deformity surgery. However, the results of this meta-analysis should be interpreted with caution because of the heterogeneity among the studies.
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Affiliation(s)
- Fei Meng
- Department of Orthopedics, The Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, Hebei, 050051, People's Republic of China
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Khoshbin A, Lysenko M, Law P, Wright JG. Outcomes of infection following pediatric spinal fusion. Can J Surg 2015; 58:006014-6014. [PMID: 25598176 DOI: 10.1503/cjs.006014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Removal of instrumentation is often recommended as part of treatment for spinal infections, but studies have reported eradication of infection even with instrumentation retention by using serial débridements and adjuvant antibiotic pharmacotherapy. We sought to determine the effect of instrumentation retention or removal on outcomes in children with spinal infections. METHODS We retrospectively reviewed the cases of patients who experienced early (< 3 mo) or late (≥ 3 mo) infected spinal fusions. Patients were evaluated at least 2 years after eradication of the infection using the following protocol outcomes: follow-up Cobb angle, curve progression and nonunion rates. RESULTS Our sample included 35 patients. The mean age at surgery was 15.1 ± 6.0 years, 65.7% were girls, and mean follow-up was 41.7 ± 26.9 months. The mean Cobb angle was 63.6° ± 14.5° preoperatively, 29.4° ± 16.5° immediately after surgery and 37.2° ± 19.6° at follow-up. Patients in the implant removal group (n = 21) were more likely than those in the implant retention group (n = 14) to have a lower ASA score (71.4% v. 28.6%, p = 0.03), fewer comorbidities (66.7% v. 21.4%, p = 0.03), late infections (81.0% v. 14.3%, p = 0.01) and deep infections (95.2% v. 64.3%, p = 0.03). Implants were retained in 12 of 16 (75.0%) patients with early infections and 2 of 19 (10.5%) with late infections. Patients with implant removal had a higher pseudarthrosis rate (38.1% v. 0%, p = 0.02) and a faster curve progression rate (5.8 ± 9.8° per year v. 0.2 ± 4.7° per year, p = 0.04). CONCLUSION Implant retention should be considered, irrespective of the timing or depth of the infection.
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Affiliation(s)
- Amir Khoshbin
- The University of Toronto Faculty of Orthopaedic Surgery and the Hospital for Sick Children, Toronto, Ont
| | | | - Peggy Law
- The Hospital for Sick Children, Toronto, Ont
| | - James G Wright
- The University of Toronto Faculty of Orthopaedic Surgery and the Hospital for Sick Children, Toronto, Ont
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Linam WM, Margolis PA, Staat MA, Britto MT, Hornung R, Cassedy A, Connelly BL. Risk Factors Associated With Surgical Site Infection After Pediatric Posterior Spinal Fusion Procedure. Infect Control Hosp Epidemiol 2015; 30:109-16. [DOI: 10.1086/593952] [Citation(s) in RCA: 120] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Objective.To identify risk factors associated with surgical site infection (SSI) after pediatric posterior spinal fusion procedure by examining characteristics related to the patient, the surgical procedure, and tissue hypoxia.Design.Retrospective case-control study nested in a hospital cohort study.Setting.A 475-bed, tertiary care children's hospital.Methods.All patients who underwent a spinal fusion procedure during the period from January 1995 through December 2006 were included. SSI cases were identified by means of prospective surveillance using National Nosocomial Infection Surveillance system definitions. Forty-four case patients who underwent a posterior spinal fusion procedure and developed an SSI were identified and evaluated. Each case patient was matched (on the basis of date of surgery, ± 3 months) to 3 control patients who underwent a posterior spinal fusion procedure but did not develop an SSI. Risk factors for SSI were evaluated by univariate analysis and multivariable conditional logistic regression. Odds ratios (ORs), with 95% confidence intervals (CIs) andPvalues, were calculated.Results.From 1995 to 2006, the mean annual rate of SSI after posterior spinal fusion procedure was 4.4% (range, 1.1%—6.7%). Significant risk factors associated with SSI in the univariate analysis included the following: a body mass index (BMI) greater than the 95th percentile (OR, 3.5 [95% CI, 1.5–8.3]); antibiotic prophylaxis with clindamycin, compared with other antibiotics (OR, 3.5 [95% CI, 1.2 10.0]); inappropriately low dose of antibiotic (OR, 2.6 [95% CI, 1.0–6.6]); and a longer duration of hypothermia (ie, a core body temperature of less than 35.5°C) during surgery (OR, 0.4 [95% CI, 0.2–0.9]). An American Society of Anesthesiologists (ASA) score of greater than 2, obesity (ie, a BMI greater than the 95th percentile), antibiotic prophylaxis with clindamycin, and hypothermia were statistically significant in the multivariable model.Conclusion.An ASA score greater than 2, obesity, and antibiotic prophylaxis with clindamycin were independent risk factors for SSI. Hypothermia during surgery appears to provide protection against SSI in this patient population.
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Shen J, Liang J, Yu H, Qiu G, Xue X, Li Z. Risk factors for delayed infections after spinal fusion and instrumentation in patients with scoliosis. J Neurosurg Spine 2014; 21:648-52. [DOI: 10.3171/2014.6.spine13636] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
There are limited published data about the risk factors for the development of delayed infections after spinal fusion and instrumentation in the population with scoliosis. The objective of this study was to evaluate the predictive factors of development of delayed infections in patients with scoliosis who underwent surgical treatment.
Methods
A total of 17 patients with scoliosis and delayed infections were identified from 3463 patients with scoliosis who received surgical treatment. The control group was composed of 85 patients with scoliosis without infections, matched for sex, age, approximate date of surgery, and diagnosis. These 2 groups were compared for demographic distribution and clinical data to investigate the predictive factors of delayed infections.
Results
The overall incidence rate of delayed infections was 0.49%. The variables of age, body mass index, and number of levels fused were similar between the 2 groups. The average primary curve magnitude for the delayed infection and control (uninfected) groups was 80.4° ± 27.0° (range 47°–135°) and 66.3° ± 11.6° (range 42°–95°), respectively (p = 0.001). Operation time in the group with delayed infections was 384.7 ± 115.9 minutes versus 254.4 ± 79.2 minutes in the control group (p = 0.000), and estimated blood loss was 1342.2 ± 707.2 ml versus 833.9 ± 235.6 ml (p = 0.000) in these 2 groups, respectively. The perioperative mean red blood cell transfusion requirement in the delayed infection group was significantly higher than that found in patients without infections (2.8 ± 2.3 units/patient versus 1.1 ± 1.6 units/patient, respectively; p = 0.000). Logistic regression analysis showed that operation time and allogenic blood transfusion were the 2 independent predictors of delayed infections (odds ratio [OR] 1.021, 95% confidence interval [CI] 1.010–1.033, and OR 1.546, 95% CI 1.048–2.278, respectively).
Conclusions
The occurrence of a delayed infection in patients with scoliosis who undergo surgical treatment is most likely multifactorial and is related to surgical time and the use of allogenic blood transfusion.
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Affiliation(s)
- Jianxiong Shen
- 1Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Beijing; and
| | - Jinqian Liang
- 1Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Beijing; and
| | - Haiquan Yu
- 2Department of Orthopaedic Surgery, Shi Jiazhuang Center Hospital, Shi Jiazhuang, Hebei, China
| | - Guixing Qiu
- 1Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Beijing; and
| | - Xuhong Xue
- 1Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Beijing; and
| | - Zheng Li
- 1Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Beijing; and
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Ryan SL, Sen A, Staggers K, Luerssen TG, Jea A. A standardized protocol to reduce pediatric spine surgery infection: a quality improvement initiative. J Neurosurg Pediatr 2014; 14:259-65. [PMID: 24971606 DOI: 10.3171/2014.5.peds1448] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Quality improvement methods are being implemented in various areas of medicine. In an effort to reduce the complex (instrumented) spine infection rate in pediatric patients, a standardized protocol was developed and implemented at an institution with a high case volume of instrumented spine fusion procedures in the pediatric age group. METHODS Members of the Texas Children's Hospital Spine Study Group developed the protocol incrementally by using the current literature and prior institutional experience until consensus was obtained. The protocol was prospectively applied to all children undergoing complex spine surgery starting August 21, 2012. Acute infections were defined as positive wound cultures within 12 weeks of surgery, defined in alignment with current hospital infection control criteria. Procedures and infections were measured before and after protocol implementation. This protocol received full review and approval of the Baylor College of Medicine institutional review board. RESULTS Nine spine surgeons performed 267 procedures between August 21, 2012, and September 30, 2013. The minimum follow-up was 12 weeks. The annual institutional infection rate prior to the protocol (2007-2011) ranged from 3.4% to 8.9%, with an average of 5.8%. After introducing the protocol, the infection rate decreased to 2.2% (6 infections of 267 cases) (p = 0.0362; absolute risk reduction 3.6%; relative risk 0.41 [95% CI 0.18-0.94]). Overall compliance with data form completion was 63.7%. In 4 of the 6 cases of infection, noncompliance with completion of the data collection form was documented; moreover, 2 of the 4 spine surgeons whose patients experienced infections had the lowest compliance rates in the study group. CONCLUSIONS The standardized protocol for complex spine surgery significantly reduced surgical site infection at the authors' institution. The overall compliance with entry into the protocol was good. Identification of factors associated with post-spine surgery wound infection will allow further protocol refinement in the future.
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Affiliation(s)
- Sheila L Ryan
- Neuro-Spine Program, Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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Incidence and risk factors for early wound complications after spinal arthrodesis in children: analysis of 30-day follow-up data from the ACS-NSQIP. Spine (Phila Pa 1976) 2014; 39:1463-70. [PMID: 24875961 DOI: 10.1097/brs.0000000000000446] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review of prospectively collected data. OBJECTIVE To determine the incidence and risk factors for 30-day wound complication after spinal arthrodesis in pediatric patients. SUMMARY OF BACKGROUND DATA Although multiple prior studies have reported on wound complications in pediatric spine, the majority have been single-center retrospective series. METHODS The National Surgical Quality Improvement Program (NSQIP) employs on-site personnel to prospectively collect 30-day morbidity data from 50 pediatric centers. Year 2012 was the first year of enrollment, and 1915 cases with thoracic or lumbar spinal fusion were included. Patients were divided into cohorts of those with and without a wound complication, with univariate and multivariate analyses used to identify risk factors. A P value of less than 0.05 was considered significant. RESULTS Wound complications occurred in 67 patients (3.5%). The incidence was significantly higher in patients with congenital (4.35%) or neuromuscular (4.67%) diagnoses, as opposed to idiopathic (2.7%) or infantile (1.61%). Procedures with fusions extending to the pelvis (9.91%) or an osteotomy (4.99%) were associated with higher risk. Longer hospital lengths of stay, increased operative time, increased patient body mass index, and patients with cardiac, gastrointestinal, neurological, or pulmonary comorbidities were also associated with a higher risk. In the multivariate analysis, a body mass index of more than 30 kg/m2, patients with cardiac risk factors, and fusions extending to the pelvis were independent risk factors. CONCLUSIONS Data from this large prospective multicenter study confirm that the incidence of early wound complications in pediatric spine surgery is low. Patients with a fusion extending to the pelvis, obese patients, and patients with significant cardiac conditions were independently associated with higher risk for this complication. These data should be useful for patients' counseling and for preoperative risk stratification. Interventions for minimizing wound complication risk may be most applicable to the high-risk groups identified here. LEVEL OF EVIDENCE 2.
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Allareddy V, Allareddy V, Nalliah RP, Rampa S, Lee MK. Infection related never events in pediatric patients undergoing spinal fusion procedures in United States: prevalence and predictors. PLoS One 2013; 8:e77540. [PMID: 24223715 PMCID: PMC3818374 DOI: 10.1371/journal.pone.0077540] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 09/11/2013] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To examine the prevalence and predictors of infection related never events (NE) associated with spinal fusion procedures (SFP) in children (age < = 18 years) in the United States. METHODS We performed a retrospective analysis of the Nationwide Inpatient Sample for the years 2004 to 2008. All pediatric hospitalizations that underwent SFP were selected for analysis. The main outcomes measures include occurrence of certain NE's. The association between the occurrence of a NE and factors (patient & hospital related) were examined using multivariable logistic regression analysis. RESULTS Of 56,465 hospitalizations, 61.7% occurred among females. The average age was 13.7 y and two-thirds were whites. The major insurance payer was private insurance (67.4%). About 82% of all hospitalizations occurred on an elective basis. Teaching hospitals accounted for a majority of hospitalizations (87.9%). Two-thirds were posterior fusion techniques, 52.3% had underlying musculoskeletal deformities, and the most frequently present co-morbid conditions (CMC) included paralysis (10.9%), chronic pulmonary disease (9.7%), and fluid/electrolyte disorders (7.6%). Overall rate of occurrence of a NE was 4.8%. Post-operative pneumonia was the most frequently occurring NE (2.9%). Female gender (OR = 0.78) and elective admissions (OR = 0.66) were associated with lower risk of NE occurrence. Medicaid coverage (OR = 1.46), primary diagnosis of other acquired deformities (OR = 1.82), spinal cord injury (OR = 6.94), other nervous system disorders (OR = 2.84) were associated with higher risk of NE occurrence. Among CMC, those with chronic blood loss anemia (OR = 2.57), coagulopathy (OR = 1.97), depression (OR = 2), drug abuse (OR = 3.71), fluid/electrolyte disorders (OR = 2.62), neurological disorders (OR = 1.72), paralysis (OR = 1.75), renal failure (OR = 5.45), and weight loss (OR = 4.61) were risk factors for higher odds of a NE occurrence. Hospital teaching status, region, hospital size, and patient race did not influence the occurrence of NE. CONCLUSION The never events examined in the current study occurred in 4.8% of children hospitalized with SFP. Certain predictors of NE are identified in this study.
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Affiliation(s)
- Veerajalandhar Allareddy
- Department of Pediatric Critical Care, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Veerasathpurush Allareddy
- Department of Orthodontics, College of Dentistry – The University of Iowa, Iowa City, Iowa, United States of America
| | - Romesh P. Nalliah
- Restorative Dentistry and Biomaterials Sciences, Harvard School of Dental Medicine, Boston, Massachusetts, United States of America
| | - Sankeerth Rampa
- Texas A & M University, College Station, Texas, United States of America
| | - Min Kyeong Lee
- Harvard School of Dental Medicine, Boston, Massachusetts, United States of America
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