- Clinical Professor of Neurological Surgery, The Albert Einstein College of Medicine, Bronx, NY 10467, and Chief of Neurosurgical Spine and Education, Winthrop University Hospital, Mineola, NY 11501, USA
Nancy E. Epstein
Clinical Professor of Neurological Surgery, The Albert Einstein College of Medicine, Bronx, NY 10467, and Chief of Neurosurgical Spine and Education, Winthrop University Hospital, Mineola, NY 11501, USA
DOI:10.4103/2152-7806.76938© 2011 Epstein NE This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Epstein NE. Preoperative, intraoperative, and postoperative measures to further reduce spinal infections. Surg Neurol Int 21-Feb-2011;2:17
How to cite this URL: Epstein NE. Preoperative, intraoperative, and postoperative measures to further reduce spinal infections. Surg Neurol Int 21-Feb-2011;2:17. Available from: http://sni.wpengine.com/surgicalint_articles/preoperative-intraoperative-and-postoperative-measures-to-further-reduce-spinal-infections/
Background:The rate of postoperative spinal infections varies from 0.4% to 3.5%. Although the introduction of additional preoperative, intraoperative, and postoperative methods of prophylaxis should further reduce spinal infection rates, these measures will not succeed unless surgeons are well informed of their availability, utility, and efficacy. This study provides a review of several preoperative, intraoperative, and postoperative methods of prophylaxis that could minimize the risk of postoperative spinal infections. Various preoperative, intraoperative, and postoperative measures could further reduce the risk of spinal infections. Preoperative prophylaxis against methicillin-resistant Staphylococcus aureus could utilize (1) nasal cultures and Bactroban ointment (mupirocin), and (2) multiple prophylactic preoperative applications of chlorhexidine gluconate (CHG) 4% to the skin. Intraoperative prophylactic measures should not only include the routine use of an antibiotic administered within 60 min of the incision, but should also include copious intraoperative irrigation [normal saline (NS) and/or NS with an antibiotic]. Intraoperatively, instrumentation coated with antibiotics, and/or the topical application of antibiotics may further reduce the infection risk. Whether postoperative infections are reduced with the continued use of antibiotic prophylaxis remains controversial. Other postoperative measures may include utilization of a silver (AgNO3)-impregnated dressing (Silverlon dressing) and the continued use of bed baths with CHG 4%. The introduction of multiple preoperative, intraoperative, and postoperative modalities in addition to standardized prophylaxis may further contribute to reducing postoperative spinal infections.
Keywords: Antibiotic prophylaxis, infection, intraoperative prophylaxis, postoperative prophylaxis, preoperative prophylaxis, spinal surgery
Multiple available preoperative, intraoperative, and postoperative methods of prophylaxis may be utilized to prevent spinal infections. Although most focus on the immediate preoperative administration of antibiotic prophylaxis within 1 h prior to surgery, little attention has been paid to other adjunctive measures that may also reduce the risk of postoperative spinal infections. Preoperative measures to reduce methicillin-resistant Staphylococcus aureus (MRSA) rates include the use of nasal cultures and Bactroban ointment (mupirocin), chlorhexidine gluconate (CHG) 4% showers/baths prior to surgery, and the utilization of clippers to remove hair rather than using razors. Perioperative measures include the timely administration of prophylactic antibiotics, the use of copious intraoperative irrigation with normal saline (NS), the implantation of antibiotic-impregnated devices, and the local application of antibiotics. Postoperative measures reaching beyond the disputed duration of antibiotic prophylaxis, may also include silver-impregnated dressings (AgNO3), and continued bathing with CHG 4%.
Although surgeons may adopt several of the adjunctive measures mentioned, the 0.4%–3.5% incidence of infections, more frequently seen with the use of spinal instrumentation, further thought should be given to basics: (1) sterile technique, (2) avoiding talking during surgery to reduce the bacterial count, (3) the meticulous handling of tissues and hemostasis, and the placement of drains[
This commentary, therefore, allows surgeons to go beyond the utilization of preoperative prophylactic antibiotics to prevent infections, or the necessity for posteroperative antibiotics to treat infections.
Nasal Colonization with Methicillin Resistant
The incidence of postoperative spinal infections with MRSA could be reduced by the preoperative culturing of patients for intranasal MRSA. One study evaluated multiple series of preoperative patients who tested positive for intranasal MRSA, and were treated prior to surgery with mupirocin (Bactroban: typically utilized b.i.d. for 7 days).[
In another study, the institution of a universal screening program included the use of nasal swabs and administration of mupirocin and chlorhexidine showers for carries of MRSA and methicillin-sensitive Staphylococcus aureus (MSSA).[
Finally, in a randomized, double-blinded, placebo-controlled multicenter trial, the frequencies of MSSA nasal carriers were identified with a real-time polymerase chain reaction (PCR) assay.[
Although the author has recently asked that most preoperative spinal patients utilize mupirocin nasal ointment the week prior to surgery, other surgeons may choose to use it in the presence of certain “risk factors for MRSA.” This includes patients with prior histories of surgery and/or other MRSA infections; they should not only utilize mupirocin prior to spinal surgery, but may benefit from a consultation from an infectious disease expert. Additionally, patients with cats/fish/other animals should also take this nasal ointment, as several of these animals are noted carriers of MRSA. There appears to be a minimal “down-side” (morbidity) for utilizing intranasal mupirocin, and most patients are compliant.
Risk Factors That Increase Operative Risk (General)
Complex protocols should be utilized to decrease the risk of infection following any type of surgery, particularly in patients with multiple comorbidities. In a cardiac surgery study, a multi-interdisciplinary approach was adopted to control/decrease the frequency of deep sternal infections.[
Presently, few surgeons are actively involved in creating strict preoperative, intraoperative, and postoperative protocols which should be adjusted according to different patients’ comorbid factors. Perhaps greater attention to these comorbid variables prior to surgery (eg, diabetes, obesity, peripheral vascular/coronary artery/pulmonary disease) would not only allow various protocols to be enacted, but may also influence the surgeon as to what he/she chooses to implant. It is certainly, well known that diabetics have a higher risk of infection and pseudarthrosis. In these patients, shorter procedures with well-controlled intraoperative and postoperative blood glucose levels, and limited/absent instrumentation may reduce the risk of infection.
Preoperative Hand Scrub Alternatives for Surgeons
Multiple new scrub techniques and products have been proposed for surgeons. One of these, Avagard (Cardinal Health, East Rutherford, NJ, USA), is a new waterless, scrubless, and brushless hand antiseptic that the Food and Drug Administration has approved to replace scrub brushes prior to surgery. In one series, Avagard was utilized as a preoperative hand/scrub preparation for urological surgeons. The operative infection rates were compared for 1800 cases prospectively performed by surgeons utilizing Avagard vs 1800 previous consecutive procedures performed utilizing traditional scrub brushes. The wound infection rate for Avagard was 2/1800 (0.11%) vs 3/1800 (0.17%) for those using the hand brushes. These results documented no significant difference between the two. Notably, all infections were managed with one course of oral antibiotic therapy, without further complications, and the hand scrub brushes were twice the cost of Avagard, with longer scrub time using the brushes.
Prior to all spinal cases, I have personally chosen to first scrub with Avagard, and follow this with the full brush technique. For any successive cases, I still would utilize both the Avagard and brushes.
Alternatives for Preoperative Skin Preparation
Minimizing the number of skin organisms utilizing preoperative skin antiseptic techniques should prove valuable in reducing postoperative infection rates. One study compared the relative efficacy of the preoperative preparation of chlorhexidine–alcohol (CA) vs povidone–iodine (PI).[
There are also different alternatives for skin preparation prior to the percutaneous implantation of devices (pacemakers, endovascular foreign bodies). Although the more common preparations are the water-soluble iodophors or CHG, alcohol-based solutions in one series proved to be “quick, sustained, and durable, with broader spectrum antimicrobial therapy.”[
In another study, multiple factors were introduced to reduce the 30% infection rate (1 million cases) that followed cesarean sections (4 million births/year).[
In a study involving total joint procedures, skin prophylaxis utilized 2% CHG no rinse cloths the night before surgery and the morning of surgery; with this CHG protocol, the infection rates were reduced from 3.19% to 1.59%.[
The patients are now asked to bathe twice a day and utilize CHG during the shower or bath, taking care to exclude the eyes, ears, and groin. Asking patients to bathe twice helps ensure that they bathe at least once per day, an important factor particularly in the older population. There have been few complaints, and it allows the patients to become active contributors, along with their spouses/ other family members, to their own safety/care.
There has been considerable discussion regarding whether intraoperative irrigation reduces the risk of infection, and what types of intraoperative irrigation (e.g. normal saline (NS) with/without antibiotics) are the best. In one study, involving children with perforated appendices, patients were managed prior to closure utilizing 1–2 L of NS wound irrigation without antibiotics.[
Another study utilized 3 different regimens with/without intraoperative irrigation to reduce the incidence of ventriculoperitoneal shunt infections.[
A further study sought to reduce spinal infections by utilizing saline irrigation in 223 consecutive cases.[
Prior to writing this review, I would irrigate every 15 min during the case with Bacitracin/Polymyxin-B sulfate, and utilize a liter of this irrigant with a pulse-evacuator at the end of the procedure. After having reviewed the literature, which focuses on the attributes of NS alone utilized at very high volumes, I have tripled (full bulb syringe ×3) the volume of antibiotic impregnated irrigation fluid utilized every 15 min.
Intraoperative Implanted Antibiotics or Antibiotic-Coated Devices
There has been interest in whether the local addition of antibiotics or antibiotic-coated instrumentation would reduce postoperative spinal infection rates. In an animal model (rabbit), Staphylococcus aureus and local antibiotics were administered. Gentamicin was administered via “controlled-release” microspheres [LGA (polylactide–;coglycolide–nanoparticles)], which yielded an adequate local concentration for up to 7 postoperative days.[
Another study utilized loading/local use of cationic antimicrobial peptides on implant surfaces to reduce surgical site infections.[
As yet, I have not adopted the use of antibiotic-impregnated devices/instrumentation, nor have I locally applied antibiotic powder into the wound itself. As more literature becomes available, and more antibiotic-impregnated devices are put on the market, both measures might become useful.
Optimal Choice and Timing of Antibiotic for Prophylaxis
To better determine whether prophylactic antibiotics reduce the risk of intradiscal infection during spinal surgery, the blood and intradiscal levels of cephazolin were assessed in 30 (average age 42 years) patients having lumbar spinal fusions.[
The Surgical Care Improvement Project (SCIP) over a 2-year period retrospectively looked at 6 variables to reduce postoperative complications, including surgical site infection due to the timely administration of preoperative antibiotics.[
Surgical infections have been reduced by the administration of preoperative antibiotics within 60 min of surgery (incision).[
For spinal cases, I typically use 2 g of Ancef (Cefuroxime) administered intravenous push within 15–30 min of the incision. For patients who are penicillin allergic, vancomycin 1 g is given slowly intravenously over 60 min. In addition to the Ancef, 80 mg of gentamicin is given over 60 min before surgery, in order to add its impact against MRSA.
Silverlon Dressings to Prevent Postoperative Infections
Silverlon, which contains the organic salt AgNO3, has been used as a topical agent in medicine for centuries. In 1968, silver sulfadiazine became available and was utilized to facilitate wound healing, particularly in the treatment of burns. More recently, various slow-release silver dressings have become available, including (Acticoat; Smith and Nephew, Largo, FL, USA), Silverlon (Argentum, Lakemont, GA, USA), and Silvasorb (Medline Industries, Inc., Mundelein, IL, USA) to reduce postoperative infections.[
The incidences of superficial vs deep infection rates were compared utilizing Silverlon dressings (SD: Silverlon; Argentum Medical, LLC, Lakefront, GA, USA) vs routine dressings (RD: gauze, alcohol swab) for 2 weeks following lumbar spinal surgery.[
I utilize Silverlon dressings (Argentum Medical, LLC, Lakefront, GA) on spinal wounds when staples rather than steri-strips are applied (typically only anterior cervical, anterior iliac crest). These dressings are removed and reapplied daily for each of 7 days after being washed with sterile water. Notably, the silver-impregnated side is applied directly to the skin, and is followed by the application of sterile gauze and tape. If, however, the dressing is soiled/dropped/contaminated, it should be replaced with a new one. The use of these dressings has effectively reduced superficial wound infections, and the need for a home health aid to assess the patients’ wounds at home has been, perhaps, the most beneficial impact derived from using this dressing.
Incidence of Postoperative Spinal Infections
The incidence of postoperative spinal infections varies from 0.4% to 3.5%.[
In another series, the rate of infection during spinal surgery was evaluated in 1597 consecutive patients receiving a single-dose vs multiple-dose antibiotic prophylaxis for varied lumbar surgical procedures (discs, degenerative spondylolisthesis, spinal stenosis, reoperations, and so on).[
In another study, in 284 patients undergoing noninstrumented spinal procedures, half received no postoperative antibiotics, while the other half did.[
Although the ideal postoperative treatment of infection following an instrumented fusion may be instrumentation removal, this may not be feasible. Alternatives to the removal of instrumentation may include the prolonged use of antibiotic therapy and wound irrigation/debridement.[
One major issue we have to deal with at present is whether we actually accept an infection rate that ranges from 0.4% to 3.5%.[
Another major consideration is whether in fact the patient requires instrumentation. Specifically, in the lumbar spine in older patients, those with osteoporosis, diabetes, or other “relevant” comorbid factors, there may be instances in which decompressions alone or with a noninstrumented (in situ) fusion rather than an instrumented fusion may be “more” appropriate. Eliminating the foreign body effectively limits both the operative time and the increased risk of infection correlated with organisms adhering to “hardware.” Furthermore, if an infection arises, there will be less need for a second operation, as there is no instrumentation to be removed. In geriatric patients, therefore, I would typically perform either no fusion or in the presence of degenerative spondylolisthesis, a noninstrumented fusion, but only rarely would add instrumentation. The short- and long-term results for the majority of these noninstrumented fusions have proved to be quite adequate.
C-reactive protein (CRP) levels in the serum may increase within 6 h following the initiation of a bacterial infection, and may be utilized to diagnose and follow the course of and treatment of infections.[
If there is a question of a postoperative infection, the use of successive erythrocyte sedimentation rate (ESR) and CRP studies has proven useful along with enhanced magnetic resonance imaging scans. Although ESR and CRP studies will typically demonstrate greater sensitivity to the effectiveness of antibiotic/other therapy, MR results tend to “lag,” demonstrating a slower “resolution” of pathological findings.
Multiple adjunctive measures may be utilized to try to limit devastating postoperative spinal infections. These include preoperative nasal cultures for MRSA and the use of prophylactic mupirocin plus preoperative bathing with CHG. Preoperative comorbid factors, particularly diabetes, increase the postoperative infection rate, as does the presence of morbid obesity. The preoperative utilization of prophylactic antibiotics supplemented with copious intraoperative irrigation with NS alone with/without antibiotics helps reduce the risk of postoperative spinal infections. Following surgery, there is no substantive data that show that continued antibiotic use reduces the postoperative infection rate, although there is a “trend” toward more resistant organisms occurring. The use of silver-impregnated dressings appears to reduce postoperative infection, which may also be detected early by following the patients’ postoperative CRPs.
Each surgeon may choose to adopt one or more of the adjuncts mentioned to limit infections following spine surgery. Critical to the limitation/elimination of infection, is the heightened awareness associated with the adoption of formal protocols, which alone may help decrease the infection rate.
1. Bode LG, Kluytmans JA, Wertheim HF, Bogaers D, Vandenbroucke-Grauls CM, Roosendaal R. Preventing surgical-site infections in nasal carriers of Staphylococcus aureus. N Engl J Med. 2010. 362: 9-17
2. Darouiche RO, Wall MJ, Itani KM, Otterson MF, Webb AL, Carrick MM. Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis, N Engl J Med 2010;362:18-28.Eiselt D. Presurgical skin preparation with a novel 2% chlorhexidine gluconate cloth reduces rates of surgical site infection in orthopaedic surgical patients. Orthop Nurs. 2009. 28: 141-5
3. Epstein NE. Do silver-impregnated dressings limit infections after lumbar laminectomy with instrumented fusion?. Surg Neurol. 2007. 68: 483-5
4. Graf K, Sohr D, Haverich A, Kuhn C, Gastmeier P, Chaberny IF. Decrease of deep sternal surgical site infection rates after cardiac surgery by a comprehensive infection control program. Interact Cardiovasc Thorac Surg. 2009. 9: 282-6
5. Hayashi T, Shirane R, Yokosawa M, Kimiwada T, Tominaga T. Efficacy of intraoperative irrigation with saline for preventing shunt infection. J Neurosurg Pediatr. 2010. 6: 273-6
6. Heggers J, Goodheart RE, Washintron J, McCoy L, Carino E, Dang T. Therapeutic efficacy of three silver dressings in an infected animal model. J Burn Care Rehabil. 2005. 26: 53-6
7. Kakimaru H, Kono M, Matsusaki M, Iwata A, Uchio Y. Postoperative antimicrobial prophylaxis following spinal decompression surgery: Is it necessary?. J Orthop Sci. 2010. 15: 305-9
8. Kanafani ZA, Dakdouki GH, El-Dbouni O, Bawwab T, Kanj SS. Surgical site infections following spinal surgery at a tertiary care center in Lebanon: Incidence, microbiology, and risk factors. Scand J Infect Dis. 2006. 38: 589-92
9. Kanayama M, Hashimoto T, Shigenobu K, Oha F, Togawa D. Effective prevention of surgical site infection using a Centers for Disease Control Prevention guideline-based antimicrobial prophylaxis in lumbar spine surgery. J Neurosurg Spine. 2007. 6: 327-9
10. Kang BU, Lee SH, Ahn Y, Choi WC, Choi YG. Surgical site infection in spinal surgery: Detection and management based on serial C-reactive protein measurements. J Neurosurg Spine. 2010. 13: 158-64
11. Kazemzadeh-Narvat M, Kindrachuk J, Duan K, Jenssen H, Hancock RE, Wang R. Antimicrobial peptides on calcium phosphate-coated titanium for the prevention of implant associated infections. Biomaterials. 2010. 31: 9519-26
12. Kim DH, Spencer M, Davidson SM, Li L, Shaw JD, Gulczynski D. Institutional prescreening for detection and eradication of methicillin-resistant Staphylococcus aureus in patients undergoing elective orthopaedic surgery. J Bone Joint Surg Am. 2010. 92: 1820-6
13. Lepor NE, Madyoon H. Antiseptic skin agents for percutaneous procedures. Rev Cardiovasc Med. 2009. 10: 187-93
14. Lipke VL, Hyott AS. Reducing surgical site infections by bundling multiple risk reduction strategies and active surveillance. AORN J. 2010. 92: 288-96
15. Nemeth TA, Beilman GH, Hamlin CL, Chipman JG. Preoperative verification of timely antimicrobial prophylaxis does not improve compliance with guidelines. Surg Infect (Larchmt). 2010. 11: 387-91
16. Potenza B, Deligencia M, Estigoy B, Faraday E, Snyder A, Angle N. Lessons learned from the institution of the Surgical Care Improvement Project at a teaching medical center. Am J Surg. 2009. 198: 881-8
17. Rauk PN. Educational intervention, revised instrument sterilization methods, and comprehensive preoperative skin preparation protocol reduces cesarean section surgical site infections. Am J Infect Control. 2010. 38: 319-23
18. Sierra-Hoffman M, Jinadatha C, Carpenter JL, Rahm M. Postoperative instrumented spine infections: A retrospective review. South Med J. 2010. 103: 25-30
19. Sookpotaroam P, Khampiwmar W, Termwattanaphakdee T. Vigorous wound irrigation followed by subcuticular skin closure in children with perforated appendicitis. J Med Assoc Thai. 2010. 93: 318-23
20. Stall AC, Becker E, Ludwig SC, Gelb D, Poelstra KA. Reduction of postoperative spinal implant infection using gentamicin microspheres. Spine. 2009. 34: 479-83
21. Walid MS, Robinson JS, Robinson ER, Brannick BB, Aijan M, Robinson JS. Comparison of outpatient and inpatient spine surgery patients with regards to obesity, comorbidities, and readmission for infection. J Clin Neurosci. 2010. 17: 1497-8
22. Walters R, Moore R, Fraser R. Penetration of cephazolin in human lumbar intervertebral disc. Spine. 2006. 31: 567-70
23. Watanabe M, Sakai D, Matsuyama D, Yamamoto Y, Sato M, Mochida J. Risk factors for surgical site infection following spine surgery: Efficacy of intraoperative saline irrigation. J Neurosurg Spine. 2010. 12: 540-6
24. Weight CJ, Lee MC, Palmer JS. Avagard hand antisepsis vs. traditional scrub in 3600 pediatric urologic procedures. Urology. 2010. 76: 15-7