Relevance of Modified Debridement-Irrigation, Antibiotic Therapy and Implant Retention Protocol for the Management of Surgical Site Infections: A Series of 1694 Instrumented Spinal Surgery

Abstract

Introduction: Management of surgical site infections (SSI) after instrumented spinal surgery remains controversial. The debridement-irrigation, antibiotic therapy and implant retention protocol (DAIR protocol) is safe and effective to treat deep SSI occurring within the 3 months after instrumented spinal surgery.Methods: This retrospective study describes the outcomes of patients treated over a period of 42 months for deep SSI after instrumented spinal surgery according to a modified DAIR protocol.Results: Among 1694 instrumented surgical procedures, deep SSI occurred in 46 patients (2.7%): 41 patients (89%) experienced early SSI (< 1 month), 3 (7%) delayed SSI (from 1 to 3 months), and 2 (4%) late SSI (> 3months). A total of 37 patients had a minimum 1 year of follow-up; among these the modified DAIR protocol was effective in 28 patients (76%) and failed (need for new surgery for persistent signs of SSI beyond 7 days) in 9 patients (24%). Early second-look surgery (≤ 7days) for iterative debridement was performed in 3 patients, who were included in the cured group. Among the 9 patients in whom the modified DAIR protocol failed, none had early second-look surgery; 3 (33%) recovered and were cured at 1 year follow-up, and 6 (66%) relapsed. Overall, among patients with SSI and a minimum 1 year follow-up, the modified DAIR protocol led to healing in 31/37 (84%) patients.Conclusions: The present study supports the effectiveness of a modified DAIR protocol in deep SSI occurring within the 3 months after instrumented spinal surgery. An early second-look surgery for iterative debridement could increase the success rate of this treatment.

Implant Retention or Removal for Management of Surgical Site Infection After Spinal Surgery

“…Of these, only 49 articles were found relevant, and were used for the synthesis below. 8 – 56 Below is the summary of their findings. Relevancy was determined purely based on if the articles answered any one of the following: (1) implant removal rate, (2) common bacterial organisms found following infection, (3) time of onset, and (4) ratio of superficial to deep infection.…”

“…39 Key steps for management included irrigation and debridement, vacuum-assisted wound closure (VAC) in 25% and more cases, and variable term antibiotics administration (both intravenous and oral). [17][18][19][20]24,28,31,36,39,44,[46][47][48][49][50][51][52][53] Many authors concluded that eradication of deep SSIs was not possible without complete removal of spinal implants. In addition, repeated site debridement could not eradicate SSI either while the implants (pedicular and/or interbody constructs) were retained, and therefore removal in most or all patients was later necessary.…”

Postoperative Spinal Implant Infections (PSII)—A Systematic Review: What Do We Know So Far and What is Critical About It?

“…49 All authors agree that cephalosporin prophylaxis should be started at a maximum of 1 hour prior to incision. 10,29,39,49,50,61,65 A repeated prophylaxis was performed by Collins et al when surgery was more than 2 hours, 31 by Liu, Lamberet and Litrico et al in operations longer than 4 hours, 10,49,72 by Fang et al after 6 hours of surgery or significant blood loss, 13 and by Pull ter Gunne et al after 4 hours or 1.5-liter blood loss. 29,61 In contrast, some authors suggest a prolonged antibiotic prophylaxis not only in selected cases but rather as a postoperative standard in all cases, independently of surgery time or 70 and Chang et al for up to 5 days.…”

“… 47 - 49 Thereby, a second look surgery might improve the therapeutic outcome in DAIR. 50 In this context, the role of DAIR in chronic cases unable to undergo implant removal / exchange due to instability or perioperative factors remains unknown.…”

“… 66 - 69 All authors cited in this systematic review, except Tofuku et al 65 (proposing a synthetic penicillin), used a first- (cefazolin, cephalothin) or second-generation (cefuroxime, cefamandole, cefonicid) cephalosporin as first line preoperative antibiotic prophylaxis. 10 , 15 , 22 , 26 , 27 , 29 , 39 , 49 , 50 , 54 , 61 Some authors additionally used a second combined preoperative antibiotic prophylaxis such as an aminoglycoside in selected cases. 22 , 70 , 71 In cases of known allergy to penicillin or cephalosporin, vancomycin was used/suggested by all authors, 10 , 15 , 29 , 50 , 61 , 72 except Bosch-Nicolau et al that suggested a combination of clindamycin and gentamycin in known beta-lactam allergy instead.…”