Intra-Wound Antibiotics and Infection in Spine Fusion Surgery: A Report from Washington State's SCOAP-CERTAIN Collaborative

Abstract

Background: Surgical site infection (SSI) after spine surgery is classified as a ''never event'' by the Centers for Medicare and Medicaid. Intra-wound antibiotics (IWA) have been proposed to reduce the incidence of SSI, but robust evidence to support its use is lacking. Methods: Prospective cohort undergoing spine fusion at 20 Washington State hospitals ( July 2011 to March 2014) participating in the Spine Surgical Care and Outcomes Assessment Program (Spine SCOAP) linked to a discharge tracking system. Patient, hospital, and operative factors associated with SSI and IWA use during index hospitalizations through 600 days were analyzed using a random effects logistic model (index), and a time-to-event analysis (follow-up) using Cox proportional hazards. Results: A total of 9,823 patients underwent cervical (47%) or lumbar (53%) procedures (mean age, 58; 54% female) with an SSI rate of 1.1% during index hospitalization. Those with SSI were older, more often had diabetes mellitus, and more frequently underwent lumbar (versus cervical) fusion compared with those without SSI (all p < 0.01). Unadjusted rates of SSI during index hospitalization were lower in patients who received IWA (0.8% versus 1.5%). After adjustment for patient, hospital, and operative factors, no benefit was observed in those receiving IWA (odds ratio [OR] 0.65, 95% confidence interval [CI]: 0.42-1.03). At 12 mo, unadjusted rates of SSI were 2.4% and 3.0% for those who did and did not receive antibiotics; after adjustment there was no significant difference (hazard ratio [HR] 0.94, 95% CI: 0.62-1.42). Conclusions: Whereas unadjusted analyses indicate a nearly 50% reduction in index SSI using IWA, we did not observe a statistically significant difference after adjustment. Despite its size, this study is underpowered to detect small but potentially relevant improvements in rates of SSI. It remains to be determined if IWA should be promoted as a quality improvement intervention. Concerns related to bias in the use of IWA suggest the benefit of a randomized trial.

Pyogenic Vertebral Osteomyelitis: Clinical Features, Diagnosis, and Treatment

“…One prospective randomized controlled study proved intrawound usage of vancomycin powder did not significantly reduce the incidence of SSI in spinal surgery90). A recent study aimed at 9,823 patients revealed about 50% reduction of SSI in intrawound antibiotics using group on unadjusted analysis, but this difference was not statistically significant after adjustment17). So far, the evidence on the benefit of intrawound vancomycin in spinal surgery is uncertain.…”

Does intrawound vancomycin powder reduce surgical site infection after posterior instrumented spinal surgery? A propensity score-matched analysis

“…Surgical site infections are associated with high morbidity, mortality, and health-care costs [1,2]. Despite the ubiquity of prophylactic antibiotics and aseptic techniques, SSIs occur at a rate of 0.6%-12% in patients undergoing instrumented spinal surgery [3][4][5][6][7][8].…”

“…Staphylococcus aureus and Staphylococcus epidermidis are the most common organisms associated with SSIs [9,10]; therefore, the use of intrawound vancomycin is considered to reduce the frequency of SSIs by killing these gram-positive cocci. However, the results of published studies have been inconsistent [5,[11][12][13][14][15]. Moreover, most published data have been based on observational before-after analyses at one center.…”

Prevention of orthopaedic infection in spine surgery

“…The use of IWA in spine surgery and especially of vancomycin-powder has minimal systemic exposure 1,42 and therefore a low rate of associated nephrotoxicity and ototoxicity 43 , allowing higher drug levels within the surgical site 1,42,44 . Its use has shown a non-significant decrease of the SSI levels 41,45 . Therefore the use of IWA is recommended from the North American Spine Society only in patients with comorbidities or for those undergoing complicated spine surgery 46 .…”

“…In a conducted study, cultures were obtained from the drapes of a C-arm in 25 cases of spine surgery 45 . It was found a contamination of the drapes in all cases.…”