Systematic Review
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. Nov 18, 2018; 9(11): 271-284
Published online Nov 18, 2018. doi: 10.5312/wjo.v9.i11.271
Analysis of a ten step protocol to decrease postoperative spinal wound infections
Hossein Elgafy, Craig J Raberding, Megan L Mooney, Kyle A Andrews, Joan M Duggan
Hossein Elgafy, Craig J Raberding, Megan L Mooney, Kyle A Andrews, Joan M Duggan, Department of Orthopedics and Infectious Diseases, University of Toledo Medical Center, Toledo, OH 43614, United States
Author contributions: All the authors contributed in outlining the manuscript, gathering the data, and writing the manuscript.
Conflict-of-interest statement: None of the authors have any financial or other conflicts of interest that may bias the current study.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Hossein Elgafy, FRCS (Ed), FRSC, MD, Professor, Department of Orthopedics and Infectious Diseases, University of Toledo Medical Centre, 3065 Arlington Avenue, Toledo, OH 43614, United States.
Telephone: +1-419-3833515 Fax: +1-419-3833526
Received: June 25, 2018
Peer-review started: June 25, 2018
First decision: July 11, 2018
Revised: July 15, 2018
Accepted: August 26, 2018
Article in press: August 26, 2018
Published online: November 18, 2018

To define a ten-step protocol that reduced the incidence of surgical site infection in the spine surgery practice of the senior author and evaluate the support for each step based on current literature.


In response to unexplained increased infection rates at our institution following spine surgery, a ten-step protocol was implemented: (1) preoperative glycemic management based on hemoglobin A1c (HbA1c); (2) skin site preoperative preparation with 2% chlorhexidine gluconate disposable cloths; (3) limit operating room traffic; (4) cut the number of personnel in the room to the minimum required; (5) absolutely no flash sterilization of equipment; (6) double-gloving with frequent changing of outer gloves; (7) local application of vancomycin powder; (8) re-dosing antibiotic every 4 h for prolonged procedures and extending postoperative coverage to 72 h for high-risk patients; (9) irrigation of subcutaneous tissue with diluted povidone-iodine solution after deep fascial closure; and (10) use of DuraPrep skin preparation at the end of a case before skin closure. Through an extensive literature review, the current data available for each of the ten steps was evaluated.


Use of vancomycin powder in surgical wounds, routine irrigation of surgical site, and frequent changing of surgical gloves are strongly supported by the literature. Preoperative skin preparation with chlorhexidine wipes is similarly supported. The majority of current literature supports control of HbA1c preoperatively to reduce risk of infection. Limiting the use of flash sterilization is supported, but has not been evaluated in spine-specific surgery. Limiting OR traffic and number of personnel in the OR are supported although without level 1 evidence. Prolonged use of antibiotics postoperatively is not supported by the literature. Intraoperative use of DuraPrep prior to skin closure is not yet explored.


The ten-step protocol defined herein has significantly helped in decreasing surgical site infection rate. Several of the steps have already been shown in the literature to have significant effect on infection rates. As several measures are required to prevent infection, instituting a standard protocol for all the described steps appears beneficial.

Keywords: Wound infections, Spine, Ten step protocol, Surgical site infections

Core tip: The rates of infection following spine surgery have been reported to range from less than 1% to 10.9% depending on the type of case. Several factors have been identified as risk for surgical site infection. In response to an increasing number of surgical site infections at the authors’ institution, a new surgical protocol was initiated in an effort to reduce infection rates after an intensive epidemiological investigation failed to reveal a common source. Institution of this bundle returned surgical site infection rates to historic level of < 1%.