Preventing surgical site infections in spinal surgery

1. Spine Conference: how to
prevent surgical site infections
in spinal surgery
1/28/2020

2. Dear Dr. Antoniades;
In 2010, an estimated 16 million operative procedures were performed in acute care
hospitals in the U.S. A recent study found that surgical site infections (SSIs) were the
most common healthcare-associated infection (HAI) accounting for 31% of infections
among hospitalized patients. Surveillance of SSI with feedback of appropriate data to
surgeons has been shown to be an important component of strategies to reduce SSI
risk.
The patient below has been identified as meeting the National Healthcare Safety
Network’s (NSHN) definition for a Deep Incisional Primary Surgical Site Infection
Criteria Met:
1.The infection occurred between 30 or 90 days of the operative procedure
(where day 1= the procedure date) AND
Involves deep soft tissues of the incision
AND
2. the deep incision is deliberately opened by a surgeon
AND an organism is identified from the soft tissues of the incision
AND patient reports localized pain.

4. 74 year old woman
Cc: Left sciatica
HPI: sx posterior lateral leg
lateral malleolus
Failed injections/PT
PMH: L3L4 and L4L5 bilateral
laminoforamenotomy 12
years ago
B TKA, RC repair, femur im
nail, DVT
PE: 5’5” 267 lb BMI 44

7. Spine (Phila Pa
1976). 2012 Sep
1;37(19):1652-6.
The distribution of
body mass as a
significant risk
factor for lumbar
spinal fusion
postoperative
infections.
Mehta AI1

8. Tobacco
age,
Diabetes
Revision surgery
Alcohol
Multiple comorbidities
Urinary incontinence
Nutrition
Neurological deficit
Obesity
Approach
Instrumentation
Blood loss
Operative time
Hematoma
Dural tear
Oxygenation
Steroids
Transfusion
seroma

10. L4L5 PSF R ICBG
L L5S1, B L4L5, L L4 hemi
B L3L4 with left L4 root exploration, L L2L3 ULBD
3.3 liters
770cc uo
4 hours 50 min
EBL 600cc
Vanco beads

11. POD #11: no complaints, no sciatica, wound good
Outside ER POD #19 GNR blood, afeb, WBC 8.8k, gross pus draining from wound
Urine: E Coli wound MRSA
Washout POD #20 incisional vac
Postop daptomycin and meropenem

12. No metaanalysis of epidemiological incidence of SSI after spinal surgery

13. Meta-analysis including 27 (399)studies, 603 cases in 22,475 patients
Pooled incidence 3.1%
Superficial SSI 1.4%
Deep SSI 1.7%
Highest incidence 13% neuromuscular, DDD 6%, trauma 5.2%, tumor 5.1%, scoliosis 2.6%
Cervical 3.4%
Thoracic 3.7%
Lumbar 2.7%
Posterior 5%
Anterior 2.3%
Instrumented 4.4%
Non-instrumented 1.4%
Minimally invasive 1.5%
Open 3.8%
Vanco powder 1.9%
No vanco powder 4.8%

14. Staphylococcus aureus 37.9%
Staphylococcus epidermidis 22.7%
Methicillin resistant Staphylococci 23.1%

15. Operative time
<3 hours 1.3%
>3 hours 4.7%

16. Blood Loss
1.9% if <500cc
3.8% if >500cc

18. Neurosurgery 80:S114–S123, 2017

20. Glycemic Control
A1C levels preop: <7 no infections
and >7 35% infections
A1C < 7.7 from joint replacement
literature (AAOS Tarabichi 2017)

21. Smoking cessation at
least 4 weeks preop

23. MRSA nasal screen
RX for 5 preop days
Vanco preop

24. Administration of
Abx within 30 min
of surgery
decreases SSI as
compared to 30-
60 min pre
incision
Every 4 hours
No drain coverage

26. Scrubs similar to
patient skin prep

27. Normothermia should be goal to decrease SSI risk

28. Double glove
Different color to notice perforation
Change gloves prior to implant

29. Vancomycin powder

30. 3.5% betadine prevents
deep SSI in spinal surgery
Cheng. Efficacy of dilute
betadine solution
irrigation in the
prevention of
postoperative infection of
spinal surgery.
Spine 2005 ; 30(15): 1689-
1693

32. Intraop O2 <50% a/w 12 fold increase in SSI
Maragakis. Intraoperative fraction of
inspired oxygen is a modifiable risk factor
for surgical site infection after spinal
surgery. Anesthesiology. 2009; 110(3); 556-
562

34. Incisional wound vac

35. Elective spine surgery seven centers over 4 years
2056 patients intrawound vanco powder 2.2% versus 5.1%
1 g Vanco powder for every 10cm of wound avoiding dura
and bone graft
Prospective not randomized per surgeon discretion
Return to OR for SSI: no vanco 3.9% and vanco powder
0.7%
Undetectable at day 4

36. thanks